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Pancreatic herniation: A rare cause of acute pancreatitis?

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Prashant Kumar at NHS Greater Glasgow and Clyde
Prashant Kumar
Matthew Turp
Matthew Turp
Matthew Turp
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Sarah Fellows
Sarah Fellows
Sarah Fellows
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Jonathan Ellis
Jonathan Ellis
Jonathan Ellis
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Abstract

Acute pancreatitis is a common and potentially fatal condition, with several well-known causes including gallstones, excessive alcohol consumption and specific medications. We report a case of an 89-year-old man presenting with acute pancreatitis, which we believe to be secondary to a diaphragmatic herniation of the pancreas. This extremely rare anatomical abnormality can be found incidentally in the asymptomatic patient or may present with a variety of acute symptoms. However, there have been only isolated reports of these cases presenting as acute pancreatitis. While the majority of acute pancreatitis cases can be explained by common causes, it is important that clinicians be aware of and should consider investigating for other more unusual possibilities, such as pancreatic herniation, before labelling an episode as 'idiopathic'.
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CASE REPORT
Pancreatic herniation: a rare cause of acute
pancreatitis?
Prashant Kumar,
1
Matthew Turp,
1
Sarah Fellows,
1
Jonathan Ellis
2
1
Department of Surgery, Milton
Keynes General Hospital,
Milton Keynes, Bucks, UK
2
Department of Radiology,
Milton Keynes General
Hospital, Milton Keynes,
Bucks, UK
Correspondence to
Dr Prashant Kumar,
prashant.kumar916@gmail.com
To cite: Kumar P, Turp M,
Fellows S, et al.BMJ Case
Rep Published online:
[please include Day Month
Year] doi:10.1136/bcr-2013-
201979
SUMMARY
Acute pancreatitis is a common and potentially fatal
condition, with several well-known causes including
gallstones, excessive alcohol consumption and specific
medications. We report a case of an 89-year-old man
presenting with acute pancreatitis, which we believe to
be secondary to a diaphragmatic herniation of the
pancreas. This extremely rare anatomical abnormality can
be found incidentally in the asymptomatic patient or may
present with a variety of acute symptoms. However,
there have been only isolated reports of these cases
presenting as acute pancreatitis. While the majority of
acute pancreatitis cases can be explained by common
causes, it is important that clinicians be aware of and
should consider investigating for other more unusual
possibilities, such as pancreatic herniation, before
labelling an episode as ‘idiopathic’.
BACKGROUND
Acute pancreatitis is a common condition encoun-
tered worldwide, with a potentially fatal outcome.
There is a well-known list of differential causes, of
which gallstones and excess alcohol consumption
are the most common in the UK.
1
In the majority
of patients, a cause can be identified following
simple investigations. However, in a significant
number of cases, no aetiology is identified, and
these are subsequently labelled as being idiopathic.
Current guidelines suggest that this proportion of
cases being classified as idiopathic should number
no more than 20%.
1
We present an extremely rare case of acute pan-
creatitis likely to have been caused by pancreatic
herniation, as opposed to other better-known
aetiologies.
CASE PRESENTATION
An 89-year-old man presented to the accident and
emergency department following a 1-day history of
epigastric pain associated with nausea and vomit-
ing. His medical history included hypertension and
ischaemic heart disease. There were no recent
changes to medications, no recent trauma and no
known history of alcohol abuse or gallstones. On
admission, he was tachycardic and hypotensive.
Initial blood work-up showed white cell count
(WCC) of 22.2×10
9
/L, C reactive protein 2.7 mg/L,
aspartate aminotransferase 242 iu/L, γ-glutamyl
transpeptidase 207 iu/L, alkaline phosphatase
165 iu/L, bilirubin 29 umol/L, albumin 39 g/L,
lactate dehydrogenase (LDH) 694 iu/L and amylase
5256 iu/L. The patient scored 3 on the Modified
Glasgow Scoring System (WCC, age & LDH), and
9 on the Acute Physiology and Chronic Health
Evaluation II score, and was therefore aggressively
resuscitated with intravenous fluids and antibiotics.
As per hospital protocol, the intensive care team
was made aware of the patient. However, following
their review, no further intensive care input was
deemed necessary at that point of time. The aeti-
ology of his pancreatitis was, at this stage, unknown.
FURTHER INVESTIGATIONS
A thorough review of the patient’s background and
medications along with initial tests found no dis-
cernable cause for pancreatitis.
The patient was shown to have a hiatus hernia
on chest X-ray from 8 years previously. The con-
tents of the hernia were not identifiable and no
other comparative imaging was available.
An abdominal ultrasound scan was requested to
investigate the possibility of gallstones, but was
reported as normal with no evidence of gallstones
or duct dilation.
Subsequently, a CT scan was performed 4 days
post-admission, which not only confirmed the pres-
ence of acute pancreatitis with inflammation of the
peripancreatic fat but also revealed a rare case of a
pancreatic herniation into the thoracic cavity
(figures 1–4). Owing to a lack of previous imaging,
we cannot be certain as to when the herniation first
appeared.
Figure 1 shows the pancreatic tail correctly fixed
in its conventional anatomical position at the level
Figure 1 Axial CT image demonstrating the pancreatic
tail fixed in its conventional anatomical position with
inflammation of the peripancreatic fat.
Kumar P, et al.BMJ Case Rep 2013. doi:10.1136/bcr-2013-201979 1
Unusual association of diseases/symptoms
of T12. Similarly, the head of the pancreas is seen to be in its
conventional anatomical position, at the level of T12 (figure 2).
The distal section of the common bile duct is dilated but is
found to be in a normal position. Unfortunately, the personnel
required to perform an additional endoscopic ultrasound to
further evaluate this finding were unavailable at Milton Keynes
Hospital.
Meanwhile, the body of the pancreas can clearly be seen, on
both axial and sagittal views (figures 3–4), to herniate above the
diaphragm, through into the thoracic cavity.
Figure 3 shows the pancreatic head at the level of T12, with
the pancreatic neck pulled superiorly into the hiatus hernia. The
apex of the pancreatic body lies at the level of the T9/T10 disc
space. The pancreatic body then takes a hair-pin turn, with the
distal aspect of the pancreatic body moving inferiorly towards
the pancreatic tail.
OUTCOME AND FOLLOW-UP
The patient was treated successfully with fluid resuscitation and
antibiotics and recovered well over the course of a 10-day
inpatient admission. He was subsequently reviewed in an out-
patient appointment. The patient was not keen for any further
investigations or invasive treatment and is therefore being
managed conservatively with omeprazole for symptomatic relief.
Surgical intervention was deemed inappropriate given his
complex comorbidities and personal wishes.
DISCUSSION
A hiatal hernia can be classified into one of the four types. Type
I, otherwise known as a sliding hernia, consists of a simple her-
niation of the gastro-oesophageal junction into the chest,
2
accounting for up to 95% of all cases.
3
The remaining 5% of
cases are classified as types II–IV or paraesophageal hernias.
3
While types II and III involve gastric herniation only, a type IV
hernia is more advanced, characterised by herniation of add-
itional abdominal organs alongside the stomach.
2
A type IV herniation is extremely rare, accounting for only
between 5% and 7% of all paraesophageal hernias,
4
with the
colon being the most common viscera to herniate in addition to
the stomach.
5
A pancreatic herniation, however, has only been
reported a handful of times.
5–13
Of these cases, there are even
fewer reported cases of this anatomical phenomenon leading to
acute pancreatitis.
11–13
In most cases, the body and tail of the
pancreas have herniated above the diaphragm. To our knowledge,
there is only one other documented case where the head and tail
of the pancreas remain in their normal anatomical planes, with
only the body of the pancreas herniating into the thoracic cavity.
5
Our findings have important implications for patients with
acute pancreatitis for which no aetiology has been identified.
Our patient demonstrates a rare anatomical abnormality that
may have been the cause of his pancreatitis. We believe that our
case contributes to the growing repertoire of similar cases in the
Figure 3 Sagittal CT image showing the folding of the pancreatic
body within the hiatus hernia.
Figure 4 Axial CT image demonstrating the apex of the body of the
pancreas within the hiatal hernia sac.
Figure 2 Axial CT image demonstrating the pancreatic head fixed in
its conventional anatomical position and dilation of the common bile
duct.
2 Kumar P, et al.BMJ Case Rep 2013. doi:10.1136/bcr-2013-201979
Unusual association of diseases/symptoms
literature which report pancreatic herniation as a potential cause
for pancreatitis. We suggest that prior to such cases being
labelled as ‘idiopathic’, clinicians should at least consider further
imaging to assess for any anatomical abnormalities. In cases
where pancreatic herniation may be the cause, surgical repair of
the hernia may help to prevent repeated episodes of acute pan-
creatitis. However, the benefit of such an intervention remains
unknown.
Learning points
▸Patients with pancreatic herniation may present with acute
pancreatitis.
▸It is imperative that the clinicians perform a thorough
diagnostic work up to elicit the cause of acute pancreatitis.
If the common causes are ruled out, then one should
consider exploration of rarer possibilities, such as anatomical
abnormalities, before labelling the cause as ‘idiopathic’.
▸Those patients fit for surgery may benefit from repair of the
hernia, so as to help prevent repeat episodes of acute
pancreatitis. However, the benefit of such an intervention
remains unknown.
Contributors All the authors were involved with patient care in this case. All the
authors have made valuable contributions to the initiation, research and writing up
of this case report.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1 UK Working Party on Acute Pancreatitis. UK guidelines for the management of
acute pancreatitis. Gut 2005;54:1–9.
2 Norton JA, Bollinger RR, Chang AE, et al.Essential practice of surgery: basic
science and clinical evidence. New York: Springer-Verlag, 2003.
3 Shieman C, Grondin SC. Paraesophageal hernia: clinical presentation, evaluation,
and management controversies. Thorac Surg Clin 2009;19:473–84.
4 Grushka JR, Grenon SM, Ferri LE. A type IV paraesophageal hernia containing a
volvulized sigmoid colon. Dis Esophagus 2008;21:94–6.
5 Coughlin M, Fanous M, Velanovich V. Herniated pancreatic body within a
paraesophageal hernia. World J Gastrointest Surg 2011;3:29–30.
6 Katz M, Atar E, Herskovitz P. Asymptomatic diaphragmatic hiatal herniation of the
pancreas. J Comput Assist Tomogr 2002;26:524–5.
7 Saxena P, Konstantinov IE, Koniuszko MD, et al. Hiatal herniation of the pancreas:
diagnosis and surgical management. J Thorac Cardiovasc Surg 2006;131:1204–5.
8 Coral A, Jones SN, Lees WR. Dorsal pancreas presenting as a mass in the chest.
AJR Am J Roentgenol 1987;149:718–20.
9 Shah N, Fernandes R, Thakrar A, et al. Diaphragmatic hernia: an unusual
presentation. BMJ Case Rep 2013;2013:pii: bcr2013008699.
10 Ahmed S, Fontaine JP, Ng T. Pancreatic herniation after transhiatal esophagectomy.
Ann Thorac Surg 2010;89:308–9.
11 Chevallier P, Peten E, Pellegrino C, et al. Hiatal hernia with pancreatic volvulus: a
rare cause of acute pancreatitis. AJR Am J Roentgenol 2001;177:373–4.
12 Maksoud C, Shah AM, DePasquale J, et al. Transient pancreatic hiatal herniation
causing acute pancreatitis—a literature review. Hepatogastroenterology
2010;57:165–6.
13 Kafka NJ, Leitman IM, Tromba J. Acute pancreatitis secondary to incarcerated
paraesophageal hernia. Surgery 1994;115:653–5.
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Kumar P, et al.BMJ Case Rep 2013. doi:10.1136/bcr-2013-201979 3
Unusual association of diseases/symptoms
... Herniation of pancreas can be without symptoms and found accidentally on imaging or as a sequel to acute pancreatitis. Acute pancreatitis as a sequela of this mechanism is very rare and has been previously reported in 13 patients [13][14][15][16][17][18][19][20][21][22][23][24][25]. Table 1 lists acute pancreatitis caused by the herniation of pancreas in HH from previous reports. ...
... Cases of pancreatic herniation with pancreatitis are rare; therefore, the ideal treatment is still unclear [20,21]. Some HH cases with pancreatitis were treated with surgery in the past [13,14,17,24], but in other cases, physicians chose conservative treatment including administration of intravenous fluids, pain killers, and diet as tolerated because of high risk of surgery [15,16] or patient's refusal to undergo operation [16,[18][19][20][21]. ...
... Cases of pancreatic herniation with pancreatitis are rare; therefore, the ideal treatment is still unclear [20,21]. Some HH cases with pancreatitis were treated with surgery in the past [13,14,17,24], but in other cases, physicians chose conservative treatment including administration of intravenous fluids, pain killers, and diet as tolerated because of high risk of surgery [15,16] or patient's refusal to undergo operation [16,[18][19][20][21]. ...
Massive hiatal hernia involving prolapse of the entire stomach and pancreas resulting in pancreatitis and bile duct dilatation: a case report
Article
Full-text available
  • Dec 2020
Background: Hiatal hernia is defined by the permanent or intermittent prolapse of any abdominal structure into the chest through the diaphragmatic esophageal hiatus. Prolapse of the stomach, intestine, transverse colon, and spleen is relatively common, but herniation of the pancreas is a rare condition. We describe a case of acute pancreatitis and bile duct dilatation secondary to a massive hiatal hernia of pancreatic body and tail. Case presentation: An 86-year-old woman with hiatal hernia who complained of epigastric pain and vomiting was admitted to our hospital. Blood tests revealed a hyperamylasemia and abnormal liver function test. Computed tomography revealed prolapse of the massive hiatal hernia, containing the stomach and pancreatic body and tail, with peripancreatic fluid in the posterior mediastinal space as a sequel to pancreatitis. In addition, intrahepatic and extrahepatic bile ducts were seen to be dilated and deformed. After conservative treatment for pancreatitis, an elective operation was performed. There was a strong adhesion between the hernial sac and the right diaphragmatic crus. After the stomach and pancreas were pulled into the abdominal cavity, the hiatal orifice was closed by silk thread sutures (primary repair), and the mesh was fixed in front of the hernial orifice. Toupet fundoplication and intraoperative endoscopy were performed. The patient had an uneventful postoperative course post-procedure. Conclusion: A rare massive hiatal hernia, involving the stomach and pancreatic body and tail, can cause acute pancreatitis with bile duct dilatation. The etiology can be flexure of the main pancreatic and extrahepatic bile ducts. Symptomatic herniation is best treated with surgery. Elective surgery is thought to be safer than emergent surgery in patients with serious complications.
View
... However, cases of acute pancreatitis caused by a prolapse of the pancreas with a large hiatal hernia have been reported previously (Table, Type 3) (6,7,(19)(20)(21)(22)(23)(24)(25)(26)(27). A diagnosis of acute pancreatitis is generally established based on abdominal symptoms accompanied by the significant elevation of pancreatic enzymes (i.e. ...
... Although our case included not only the head of the pancreas but also the body and tail as prolapsed parts into the mediastinum, we consider this case as one of pattern A. Meanwhile, in patients with pure type 3 pancreatic herniation, only 1 of 10 cases (10%) involved the head of the pancreas as a herniated portion of the hiatal hernia, and in most cases, the body or tail of the pancreas migrated into the mediastinum (pattern B, Fig. 4B). Kumar et al. also pointed out that most cases with pancreatitis secondary to a hiatal hernia had herniation of the pancreatic body and tail (22). Tomida et al. summarized 14 previously reported cases with acute pancreatitis secondary to a large hiatal hernia. ...
Hiatal Hernia with Prolapse of the Pancreas Causing Bile Duct Stricture and Liver Function Disorders: A Case Report and Literature Review
Article
Full-text available
  • May 2023
Hiatal hernia is a common condition in elderly patients, but the additional presence of prolapse of the pancreas is extremely rare. We herein report an 89-year-old woman who presented with liver function disorders and abdominal pain. Her laboratory tests revealed cholestasis, and imaging examinations showed stenosis of the common bile duct pulled toward the hernia sac. She was diagnosed with a common bile duct stricture due to pancreatic herniation and underwent laparoscopic surgery. Our review of the literature identified three types of pancreatic herniations: asymptomatic, bile duct complication, and acute pancreatitis. Pancreatic head herniation tends to induce bile duct complications.
View
... Cases of pancreatic herniation with pancreatitis are rare; Therefore, the ideal treatment is still unclear [1,3,6]. However, conservative treatment including intravenous fluid supplementation, analgesia and early feeding is usually indicated [1,11,12]. ...
... Historically, HH cases with pancreatitis were treated with surgery [1,6,7,13,14]. However, the benefit of such intervention remains unknown especially that the rate of recurrence appears to be low [3,12]. Moreover, the decision to pursue surgical repair should be considered on a case-by-case basis since most affected patients are of advanced age. ...
The uncommon diagnosis of hiatal hernia associated pancreatitis: A case report
Article
Full-text available
  • Jun 2022
Introduction and importance Hiatal hernia (HH) contents commonly include stomach, transverse colon, small intestine, and spleen but herniation of the pancreas is an extremely rare phenomenon, even rarer when HH is associated with acute pancreatitis. Case presentation A 56-year-old female with hypertension and gastroesophageal reflux disease presented with abdominal pain, vomiting and chest discomfort evolving for 24 h. Physical examination revealed left-upper quadrant tenderness without guarding. Blood tests showed elevated serum amylase and lipase levels. An abdominal CT scan demonstrated a large type-IV hiatal hernia involving the entire stomach, transverse and right colon, small intestine, duodenum as well as the head, body and the tail of pancreas. The pancreas was enlarged consistent with pancreatitis. Patient clinical status improved with conservative treatment. Clinical discussion The stomach is the most common organ to herniate through the diaphragm and pancreatic herniation is extremely rare with only few cases in the literature. Even rarer when associated with acute pancreatitis. This diagnosis is a major diagnostic and therapeutic challenge that has to be evoked in elderly presenting with chest pain and a negative cardiopulmonary evaluation. The ideal treatment is still unclear, however, conservative treatment is the initial management and surgery may be considered in case of recurrent episodes of acute pancreatitis. Conclusion HH associated with acute pancreatitis is a major diagnostic and therapeutic challenge. Clinicians should consider this rare diagnosis in every case of chest pain with negative cardiopulmonary evaluation.
View
... In the last 25 years, 17 cases of intrathoracic herniation of (parts of) the pancreas have been reported (Table 1) [2][3][4]6,[8][9][10][11][12][13][14][15][16][17][18][19][20]. In the majority of cases, the pancreatic herniation itself was asymptomatic and found incidentally [2,4,[8][9][10][11][12][16][17][18][19][20] on CT-scans made for evaluating complaints befitting a large or giant hiatal hernia such as abdominal pain [4,10,11,[16][17][18][19], vomiting [17,18], dysphagia [4] or dyspnea [2,16,20]. ...
... In the majority of cases, the pancreatic herniation itself was asymptomatic and found incidentally [2,4,[8][9][10][11][12][16][17][18][19][20] on CT-scans made for evaluating complaints befitting a large or giant hiatal hernia such as abdominal pain [4,10,11,[16][17][18][19], vomiting [17,18], dysphagia [4] or dyspnea [2,16,20]. Five cases, however, were diagnosed with pancreatitis secondary to intrathoracic pancreatic herniation [3,6,[13][14][15], one of which was associated with pancreatic torsion [6]. While pancreatitis is known to occur as a result of pancreatic herniation, large and giant hiatal hernia without pancreatic involvement may also present with acute or recurrent pancreatitis. ...
Laparoscopic Hiatal Hernia Repair in Patients with an Intrathoracic Pancreas: Case Series and a Review of Literature
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  • Feb 2020
Transhiatal herniation of the pancreas is rare with only 17 cases reported in 25 years. Presentation of pancreatic herniation is diverse. In the majority of cases, the pancreatic herniation is found incidentally on CT-scans made for evaluating complaints related to a large or giant hiatal hernia. We present a literature review and case series of three patients with symptomatic type IV hiatal hernia with incidental, asymptomatic pancreatic herniation. All cases were managed laparoscopically with robotic assistance.
View
... Trans-diaphragmatic hernia of pancreas can be asymptomatic and found incidentally on imaging or result in acute pancreatitis. Table 1 [3,[7][8][9][10][11][12][13][14][15] lists the cases of acute pancreatitis from pancreatic herniation in hiatal hernias from published literature. All cases were diagnosed based on exclusion of other etiologies for acute pancreatitis. ...
View
... However, herniation of the pancreas is extremely rare, as the pancreas is a well-fixed organ. There are few reported cases about herniation of the body of the pancreas when the head and tail remain in normal anatomical cavities [2]. ...
Asymptomatic pancreatic body herniation complicated with periauricular squamous cell carcinoma
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Hiatus hernia is defined as herniation of the abdominal elements through the esophageal hiatus into the madiastinum. Type IV hiatal herniation is the rarest of all paraoesaphagial hernias. Herniation of pancreas is extremely rare. A 63-year-old male was admitted to the department of oncology with a periauricular squamous cell carcinoma (SCC). Abdominal CT was performed for organ metastasis. No metastasis was found, but hiatal herniation of the stomach along with the body of the pancreas into the thorax was observed. To our knowledge, this is the first case of herniated pancreatic body complicated with a carcinoma in the literature.
View
Pancreatitis aguda necrosante secundaria a hernia de hiato grado IV complicada: Presentación de un caso y revisión de la literatura
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Introducción. En las hernias paraesofágicas tipo IV se produce la herniación del estómago junto a otros órganos abdominales. La herniación del páncreas es muy infrecuente. Caso clínico. Varón de 57 años que acude por dolor torácico, disnea e intolerancia al decúbito. En la tomografía computarizada toracoabdominal se observa hernia diafragmática que contiene colon transverso, intestino delgado y páncreas, con reticulación de la grasa alrededor del mismo, compatible con pancreatitis aguda. Conclusión. La asociación de hernia hiatal con páncreas herniado y pancreatitis es extremadamente infrecuente. El diagnóstico se estableció mediante tomografía computarizada y el tratamiento fue conservador, con cirugía diferida de la hernia de hiato.
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Rare sequalae of hiatal hernia causing pancreatitis and hepatitis: A case report
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BACKGROUND Hiatal hernia (HH) contents commonly include stomach, transverse colon, small intestine, and spleen but herniation of the pancreas is an extremely rare phenomenon. CASE SUMMARY 79-year-old female with multiple comorbidities presented to emergency department with complaints of weight loss for 6 mo and abdominal pain for one day. Physical examination revealed cachectic and dehydrated female and bowel sounds could be auscultated on the right side of chest. Computed tomography of the chest and abdomen revealed interval enlargement of a massive HH, containing stomach and much of the bowel as well as pancreas and distal extra-hepatic biliary duct, probably responsible for obstructive effect upon same. There was increased prominence of the pancreas consistent with pancreatitis. There was a large HH causing obstructive effect with dilated biliary system along gall bladder wall edema and pancreatitis. Patient clinical status improved with conservative treatment. CONCLUSION HH presenting with acute pancreatitis is a serious diagnostic and therapeutic challenge. The initial management is conservative, even if the abdominal content has herniated to mediastinum. The incentive spirometry can be utilized in the conservative of the large HH. After stabilization of the patient, elective surgical intervention remains the mainstay of the management. Definitive treatment will vary from case to case depending on the acuity of situation and comorbidities.
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Diaphragmatic hernia: An unusual presentation
Article
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  • Apr 2013
A 53-year-old lady presented to A&E with a 3-day history of severe epigastric pain and vomiting. This was preceded by a 3-month history of generalised abdominal discomfort, early satiety and increasing shortness of breath. A CT scan showed a left-sided posterior diaphragmatic defect. Urgent repair of the hernia showed herniation of three-quarter of the stomach, half of the transverse colon, the 13 cm spleen and the pancreas in the chest. There were no postoperative complications. Traumatic diaphragmatic hernias are known to be a complication of major trauma. However, the patient in this case report presented acutely, after mild physical trauma related to using a rowing machine. This exercise, when not performed correctly can raise intra-abdominal pressure. It is plausible that this trauma, although mild, was sufficient in causing the lady's diaphragmatic hernia. This case would suggest that the trauma required to cause a diaphragmatic hernia need not be as severe as originally thought.
View
Herniated pancreatic body within a paraesophageal hernia
Article
Full-text available
  • Feb 2011
A hiatal hernia can be classified as one of four types according to the position of the gastroesophageal (GE) junction and the extent of herniated stomach. Type I, or sliding hernias, account for up to 95% of all hiatal hernias and occur when the GE junction migrates into the posterior mediastinum through the hiatus. Type II occurs when the fundus herniates through the hiatus alongside a normally positioned GE junction. Type III is a combination of types I and II hernias with a displaced GE junction as well as stomach protruding through the hiatus. Type IV paraesophageal hernias are the rarest of the hiatal hernias. Usually, colon or small bowel is herniated within the mediastinum along with the stomach. We present a case of a paraesophageal hernia with the mid-body of the pancreas as part of the hernia contents.
View
Surgery: Basic Science and Clinical Evidence
Book
  • Jan 2001
had a dream. My dream was to assemble the current and future leaders in surgery and ask them to develop an evidence-based surgical textbook that would provide the reader with the most up-to-date and relevant information on which to base decisions in modern surgical practice. In other words, the dream was to create the best, most comprehensive textbook of surgery. Fortunately, I met Laura Gillan of Springer-Verlag New York, who had a similar dream. As our editor, she has provided the foundation and structure for this dream. She has made this dream a reality. Because surgery is a highly specialized and diverse discipline with significant complexity, I also needed a commitment from outstanding sur­ geons to serve as coeditors. I was fortunate to have a diverse group of exceptional, young-in-spirit, en­ ergetic, cutting-edge, surgical investigators share in this project, and I wish to thank them for their in­ valuable contribution to this undertaking. The Editorial Board, including Randy Bollinger, Fred Chang, Steve Lowry, Sean Mulvihill, Harvey Pass, and Robert Thompson, met for the first time at the Ameri­ can College of Surgeons meeting in Chicago in October 1997 (Fig. 1). There, this book was conceived. Each of us developed the plan and content for his specific surgical discipline. The common thread is that all decisions and recommendations are based on the best available evidence and that the reader can clearly see the evidence in our "E-tables" (evidence-based tables) specifically marked for the reader's reference.
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Dorsal pancreas presenting as a mass in the chest
Article
  • Oct 1987
A unique case is presented of a patient with a mass on chest radiographs that proved to be a herniated dorsal pancreas. The position of the hernia in the posteromedial part of the right leaf of the diaphragm indicates that the patient had a persistent pneumoenteric recess. The embryologic origin and the implications for diagnosis are discussed.
View
Transient Pancreatic Hiatal Herniation Causing Acute Pancreatitis - A Literature Review
Article
  • Jan 2010
  • HEPATO-GASTROENTEROL
Acute pancreatitis is a common cause for hospitalization; in the majority of cases, there is an identifiable etiology. However, a significant number of cases remain idiopathic. Herniation of the pancreas through a diaphragmatic hiatal hernia is an extremely rare condition reported in only five cases in the English literature. Herein, we provide a review of this topic, which includes our experience with a case of documented transient pancreatic herniation causing acute pancreatitis.
View
Paraesophageal Hernia: Clinical Presentation, Evaluation, and Management Controversies
Article
  • Nov 2009
  • Thorac Surg Clin
Practically, hiatal hernias are divided into sliding hiatal hernias (type I) and PEH (types II, III, or IV). Patients with PEH are usually symptomatic with GERD or obstructive symptoms, such as dysphagia. Rarely, patients present with acute symptoms of hernia incarceration, such as severe epigastric pain and retching. A thorough evaluation includes a complete history and physical examination, chest radiograph, UGI series, esophagogastroscopy, and manometry. These investigations define the patient's anatomy, rule out other disease processes, and confirm the diagnosis. Operable symptomatic patients with PEH should be repaired. The underlying surgical principles for successful repair include reduction of hernia contents, removal of the hernia sac, closure of the hiatal defect, and an antireflux procedure. Debate remains whether a transthoracic, transabdominal, or laparoscopic approach is best with good surgical outcomes being reported with all three techniques. Placement of mesh to buttress the hiatal closure is reported to reduce hernia recurrence. Long-term follow-up is required to determine whether the laparoscopic approach with mesh hiatoplasty becomes the procedure of choice.
View
Pancreatic Herniation After Transhiatal Esophagectomy
Article
  • Jan 2010
Diaphragmatic herniation as a complication after esophagectomy has been described. Contents within the hernia sac have been mainly limited to the small bowel and colon. We believe this is the first case report in the literature of a pancreatic herniation after esophagectomy. The incidence, presentation, technical risk factors, and treatment of post-esophagectomy diaphragmatic hernias are discussed.
View
Acute pancreatitis secondary to incarcerated paraesophageal hernia
Article
  • Jun 1994
  • SURGERY
Paraesophageal hiatus hernia can be a morbid and even lethal condition. Although many complications from this entity have been described, they almost always involve gastric incarceration and its related complications. Occasionally, the transverse colon or spleen may be involved in the hernia, causing additional symptoms. An unusual case of paraesophageal hiatus hernia involving incarceration of the pylorus, proximal duodenum, and pancreatic head is described. The patient's presentation, operative management, and perioperative course are discussed to emphasize the importance of early elective repair of paraesophageal hiatus hernia before the development of such occurrences.
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Asymptomatic Diaphragmatic Hiatal Herniation of the Pancreas
Article
  • Jul 2002
Herniation of the pancreas into a diaphragmatic hiatal hernia is a rare condition reported in only three cases; all were symptomatic. We present a CT diagnosis of hiatal hernia containing the body and tail of a normal pancreas in an asymptomatic patient.
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