1 PB
1 PB
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ORYGINALNA
REPORT
Jan Lesinski 1, Tadeusz M. Zielonka 1, 2, Olga Wajtryt 1, Krystyna Peplinska 3, Aleksandra Kaszynska 3
1
Clinical Department of Internal Medicine, Czerniakowski Hospital in Warsaw, Poland
2
Departement of Family Medicine, Warsaw Medical University, Warsaw, Poland
3
Department of Internal Medicine and Cardiology, Solec Hospital in Warsaw, Poland
Abstract
Dyspnoea is most often caused by disorders of the respiratory and/or cardiovascular systems. Much less often it is brought about
by the displacement of abdominal organs into the thoracic cage. Hiatal hernias may give rise to diagnostic difficulties, as both
clinical and radiological symptoms suggest different disorders. Computed tomography is the method of choice when making
a diagnosis.
We have presented a series of 7 cases of giant hiatal hernias, each with a varying course of the disease, clinical symptoms,
radiological features and prognoses.
In two of the cases, the hernias were of a post-traumatic nature. Four cases of large diaphragmatic hernias were found in elderly
patients (over 90 years old). An advanced age and numerous coexisting chronic diseases disqualified most of the patients from
surgical treatment despite the hernias’ large sizes. In only one case was fundoplication performed with a good end result. Two
patients died, and an extensive hernia was the cause of one of the deaths. Upper gastrointestinal symptoms were present only
in a few of the patients.
An early diagnosis of giant hiatal hernia is crucial for the patients to undergo prompt corrective surgeries.
Key words: acquired diaphragmatic hernia, dyspnoea, elderly patients, gastroesophageal reflux disease, kyphoscoliosis, hiatal
hernia
Adv Respir Med. 2019; 87: 54–62
Address for correspondence: Tadeusz M. Zielonka, Departement of Family Medecine, Warsaw Medical University, Stepinska street 19/25, 00–739 Warsaw, Poland,
e-mail: tadeusz.zielonka@wum.edu.pl
DOI: 10.5603/ARM.a2019.0009
Received: 27.10.2018
Copyright © 2019 PTChP
ISSN 2451–4934
54 www.journals.viamedica.pl
Jan Lesinski et al., Hiatal hernias
Case study
Case 1
A 94-year-old female, leading a sedentary
lifestyle for the past three years due to a surgi-
cally operated intertrochanteric hip fracture, was
admitted to hospital because of general condition
deterioration and acute renal failure caused by de-
hydration secondary to decreased food and fluid Figure 1. Posterior–anterior chest X- ray. An image of a large sliding
intake. Her medical history included abdominal hernia, with the gastrointestinal tract visible in the midline (arrows)
pain, nausea, regurgitation aggravated by meals
and orthopnoea. On admission, the patient was
in a fair medical condition, with slight dyspnoea,
but no respiratory distress (SaO2 98%, BP 150/90
mm Hg, HR 70/min). Normal breath sounds were
heard over both lungs, the abdomen was soft,
but painful in the epigastrium on palpation. The
patient also presented with abnormal laboratory
values: GFR 20 mL/min/1.73m2; urea 183 mg/mL,
Na+ 126 mmol/L. The chest X-ray showed a large
shadow with a diameter of 95 mm overlying the
heart (Fig. 1). The chest CT revealed a large hia-
tal hernia with translocation of nearly the entire
stomach into the thoracic cage (Fig. 2). The hiatus
was estimated to have 55 mm in diameter. Due
to the patient’s advanced age and a high risk of
complications, the woman was disqualified from
surgery. The treatment (i.v. proton pump inhibi-
tor, fluids) led to a significant improvement in the
patients’ clinical state and in laboratory values,
a relief of dyspnoea and abdominal pain, and an Figure 2. Computed tomography of the chest. The shadow observed
improvement in kidney function. On discharge, in the chest X-ray was caused by a large hernia (black arrows) of the
esophagus with displacement of the stomach into the chest
the woman was recommended to eat in a recli-
ned position, and follow a suitable diet (small,
frequent meals, avoidance of foods increasing of congestion on lung auscultation and increased
gastroesophageal reflux disease symptoms). peripheral oedema. Laboratory studies reve-
aled a raised level of NT-proBNP (1085 pg/mL).
Case 2 Scoliosis and a mass in the middle lobe of the
A 92-year-old female with severe kyphosco- right lung connecting with the right hilum were
liosis, chronic heart failure, permanent atrial described in the chest X-ray (Fig. 3). The chest
fibrillation, deep vein thrombosis treated with CT showed a large hiatal hernia, lung emphysema
anticoagulants, posthaemorrhagic stroke, was and fibrosis, atelectasis in the second segment of
admitted to the clinic due to an exacerbation of or- the right lung, and also enlargement of multiple
thopnoea. On admission, the patient was in a fair hilar and mediastinal lymph nodes up to 14 mm
general condition and presented with tachypnoea, (Fig. 4). Diuretic use led to a decrease in dyspnoea
an irregular HR of around 85/min, SaO2 94%, signs and total regression of oedema. The patient was
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Advances in Respiratory Medicine 2019, vol. 87, no. 1, pages 54–62
Figure 4. Computed tomography of the chest. Deformation of the Figure 5. A — posterior–anterior chest X- ray; B — lateral chest X- ray.
chest, a large hiatal hernia (arrows), atelectasis in the right lung, and A significant scoliosis and a brighter area partially projecting onto the
enlargement of multiple hilar and mediastinal lymph nodes heart silhouette (black arrows)
released home in a stable condition. After 2 years tory studies showed an increase in CRP (6.1 ng/
she was readmitted with a diagnosis of communi- dL), and NT-proBNP (4386 pg/mL). The chest CT
ty acquired pneumonia. The woman complained revealed a persistent large hiatal hernia with the
of a cough, expectoration of a large amount of stomach protruding into the thoracic cage, as well
a mucopurulent secretion, dyspnoea and dyspep- as signs of increasing pulmonary hypertension.
tic symptoms after meals. These signs intensified The EF was 60% in the ECHO, and also large tricu-
when compared to the previous hospitalisation. spid regurgitation with Right Ventricular Systolic
On patient examination, attention was turned to Pressure RSVP of 70 mm Hg were described. The
the severe deformation of the thoracic cage, an woman received oxygen therapy, a loop diuretic,
irregular HR of around 90/min, BP 140/100 mm a mucolytic agent and an antibiotic obtaining an
Hg, SaO2 89%, signs of congestion over the lung improvement in her medical state. The patient
fields and intensified peripheral oedema. Labora- observed a decrease in nausea after the implemen-
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Jan Lesinski et al., Hiatal hernias
Case 3
A 96-year-old male with chronic heart failure,
persistent hip and knee joint pain due to osteoar-
thritis, treated with hormone therapy for prostate
cancer for the past couple of years, as well as
citalopram and donepezil due to a mild depres-
sive disorder, was admitted to hospital because
of a decline in his general condition, increasing
weakness for the past month, dizziness and brady-
cardia of around 38–50/min. He denied episodes
of fainting, loss of consciousness and chest pain.
He didn’t complain of dyspnoea or decreased
exercise tolerance. There were no gastrointestinal
problems such as nausea, vomiting, dyspeptic
symptoms or heartburn. The patient was fully Figure 6. Computed tomography of the chest. A large hiatal hernia
oriented, mobile, and aware of his conditions. imitating a tumour in the mediastinum (arrow)
Laboratory studies revealed increased levels of
NT-proBNP (1688 pg/mL). The ECG showed sinus
bradycardia of 51/min, PQ 0.19 s, elongation of She had been bedridden with right-sided hemi
the QT interval (490 ms), QRS 113 ms, without -paralysis for the past four years due to a stroke.
signs of ischemia. The 24-hour ECG Holter moni- She had hypertension, chronic atrial fibrillation
toring registered a sinus rhythm of 59/min, with with chronic heart failure. On admission to ho-
episodes of bradycardia down to 45/min, without spital, muscle atrophy and oedema of the lower
any relevant pauses, an average elongation of the limbs were noted. On lung auscultation, breath
QT interval to 481 ms, maximally to 568 ms, but sounds were normal. Laboratory studies revealed
without any significant ventricular arrhythmias. an increase in inflammatory markers (CRP 1.85
The echocardiogram showed an enlarged left mg/dL, WBC 17 ×103/mL) and hyponatraemia
atrium, diastolic dysfunction, moderate aortic, (124 mmol/L), with normal concentrations of
mitral and tricuspid valve insufficiency, and an troponin, D-dimers and haemoglobin. An arterial
EF of 65%. Drug-induced QT-prolongation was gasometry was done: pH 7.41, PaCO2 47 mm Hg,
suspected. Citalopram and donepezil were di- PaO2 55 mm Hg, HCO3 29.8 mmol/L. The chest
scontinued. The chest X-ray revealed a brighter X-ray showed a huge hiatal hernia with translo-
area of 55 × 70 mm in size in the left side of the cation of the entire stomach into the chest (Fig.
thoracic cage, partially projecting onto the heart 7). A nasogastric tube was placed, the patient
silhouette, described as a thick-walled cavity with received fluids intravenously, ceftriaxone, me-
features of atelectasis on the periphery or a hiatal tronidazole and oxygen therapy. There was no
hernia (Fig. 5). The chest CT showed a large hiatal change in the woman’s medical condition and
hernia imitating a tumour in the mediastinum the patient passed away after 72 hours.
(Fig. 6). Because of the asymptomatic course, the
only changes in therapy included conservative Case 5
treatment involving headrest elevation and ke- A 70-year-old male with coronary artery
eping an upright position for at least 30 minutes disease, after a bypas (CABG) and subsequent
after meals. angioplasty (PTCA) with implantation of two
stents, with ischaemic cardiomyopathy, hyper-
Case 4 tension, type 2 diabetes treated with insulin,
postischaemic stroke with subsequent left-sided
A 95-year-old female was admitted to hospi- hemiplegia, suffered a spinal injury after hitting
tal due to suspected pneumonia. Her general con- a wall when trying to drive out of the garage. The
dition was poor. She had substantial dyspnoea at CT revealed fractures of vertebrae Th10 and Th11,
rest because of cardiorespiratory failure (irregular as well as the arch of C7, fluid in both pleural
HR around 120/min, BP 90/60 mm Hg, SaO2 80%). cavities, and a substantial hiatal hernia with
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Advances in Respiratory Medicine 2019, vol. 87, no. 1, pages 54–62
Figure 7. Anterior–posterior chest X-ray. A huge hiatal hernia with Figure 8. Posterior–anterior chest X-ray. A large diaphragmatic hernia is
translocation of the entire stomach into the chest (black arrows) visible at the base of the lung (black arrows) with a diameter of 21 cm
translocation of the stomach into the thoracic sition, the tube curled within the hernia (Fig. 9).
cavity. The patient was not at that time qualified The man was disqualified multiple times by
for surgery. After the accident, he remained in surgeons from surgical treatment, mainly due to
a supine position or in a corset. He reported heart failure. The patient’s condition gradually
increased nausea, vomiting after food or fluid deteriorated. In addition, he presented with diar-
intake and also presented with increasing retro- rhoea caused by Clostridium difficille. During the
sternal chest pains of a non-ischaemic character, course of vancomycin treatment, the man went
appearing after meals and lasting around 1 hour. into cardiac arrest in the mechanism of asystole,
For this reason, he was admitted to the general and despite cardiopulmonary resuscitation, there
ward. On admission, vital signs were normal (BP was no return of vital functions.
110/70 mm Hg, HR 98/min, SaO2 95%). The chest
X-ray showed atelectasis located near the heart Case 6
in the left lung, a significantly enlarged heart An 87-year-old woman, chronically treated
and moderate pulmonary congestion (Fig. 8). only for arterial hypertension, was admitted to
Circulatory treatment was intensified with a cli- hospital due to fluid in the right pleural cavity.
nical improvement. The patient was discharged Three weeks earlier she sustained a thoracic cage
home and was advised to eat frequent small por- injury after falling over and hitting a chair. The
tions with a raised headrest and not eat while in chest X-ray revealed fractures of ribs VI, VII, VIII
a supine position. After two weeks the man was and IX on the right side and changes suggesting
readmitted to hospital with forceful vomiting a large oesophageal hernia (Fig. 10). For the past
after meals. A nasogastric tube was inserted, and couple of weeks she had significantly decreased
600 mL of retained fluid was obtained in a short her food intake due to a lack of appetite and
period of time with a marked alleviation of symp- nausea. On physical examination, she presented
toms. Gastroscopy was performed revealing the with decreased breath sounds at the base of the
body and fundus of the stomach to be in the tho- right lung as well as reduced fremitus and dull-
racic cage as well as inflammatory changes of the ness on percussion (BP 154/81 mm Hg, HR 69/
mucous membrane. Intravenous fluid supplemen- min, SaO2 96%). Laboratory tests showed a slight
tation, a proton pump inhibitor, metoclopramide, decrease in sodium concentration (131 mmol/L)
antibiotics to treat a urinary tract infection and and haemoglobin (11.9 g/dL), and an increase in
intensive insulin therapy were used. Increasing D-dimers up to 2895 ng/mL. The chest CT showed
emaciation and hypoalbuminaemia were ob- a large oesophageal hernia, a 5 cm in diameter
served. After consulting the gastroenterologist, polypoid structure with polycyclic features on the
tube feeding was used parenterally, and subsequ- anterior stomach wall and a widened oesophagus
ently, a Ryles nasogastric tube was inserted. Ho- up to 35mm partially filled with fluid (Fig. 11).
wever, when the patient remained in a supine po- During gastroscopy, a large sliding hernia with
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Jan Lesinski et al., Hiatal hernias
Figure 9. Anterior–posterior chest X-ray. Arrows pointing at the right Figure 11. Computed tomography of the chest showed a large oe-
side of hernia and at the left side the tube curled within the hernia sophageal hernia (arrows), a 5 cm in diameter polypoid structure
(black arrows) with polycyclic features on the anterior stomach wall and a widened
oesophagus up to 35 mm partially filled with fluid
Figure 10. Posterior–anterior chest X-ray. Arrows pointing at the Figure 12. Computed tomography of the chest revealed a shadow,
heart silhouette suggesting a large oesophageal hernia 8 cm in diameter, in the lower mediastinum with a visible fluid level
— an oesophageal hernia (black arrows)
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Jan Lesinski et al., Hiatal hernias
factors like obesity and the tissue degeneration cal symptoms, such as haemodynamic instability
associated with age. In the literature, we can find caused by a large diaphragmatic hernia [31], chan-
reports suggesting a relationship between the oc- ges suggesting an acute myocardial infarction
currence of GERD symptoms and diaphragmatic [32], left ventricle compression by a large hernia
hernias and obesity [27, 28]. However, in the [33] and fainting after a meal [34], dominate.
discussed group, none of the patients were obese. What is surprising, only one patient compla-
This agrees with Japanese results, which indica- ined of a cough, which was rather connected to
ted a higher incidence of diaphragmatic hernia a respiratory tract infection and was not chronic.
symptoms in middle-aged obese men and elderly Diaphragmatic hernias contribute to the develop-
women with a low BMI [16]. ment of GERD, which is an important cause of
In the presented cases, attention is drawn non-pulmonary cough [35]. Meanwhile, in cases
to the varied clinical course of diaphragmatic of large diaphragmatic hernias this symptom was
hernias (Table 1). In two patients, who were after not observed. On the other hand, dyspnoea was
thoracic cage trauma with fractured ribs or ver- reported by 5 patients and respiratory failure
tebrae, gastric symptoms (nausea and vomiting was diagnosed in 3 cases. Respiratory symptoms
after meal consumption) worsened rapidly le- occurred mostly in an acute disease presentation
ading to dehydration. However, in two subsequ- or in cases of overlapping disorders (for example
ent patients, serious injuries and bone fractures pneumonia with a diaphragmatic hernia or heart
were also noted, but GERD symptoms progressed failure with a diaphragmatic hernia). It is belie-
gradually and were accompanied by dyspnoea. ved that dyspnoea is not a common symptom of
In the literature, the importance of trauma as diaphragmatic hernias [36]. It may be the result
a causative agent in the formation of diaphragma- of ventilation or perfusion abnormalities [37].
tic hernias has been underlined [24, 25, 29, 30]. Despite the large sizes of hernias, gastrointesti-
Violent thoracic or abdominal trauma leads to nal symptoms did not occur in all of the patients.
diaphragmatic injury in 0.8–15% of cases [29]. Five patients reported nausea, 4 complained of GERD
In some of these cases, patients present with ra- symptoms, and 3 of vomiting. Abdominal pain occur-
pidly worsening symptoms leading to a quicker red in 3 of the subjects. The literature has underlined
diagnosis. Hernia symptoms are not always so the importance of these symptoms in patients with
pronounced, which is why the diagnosis may be hiatal hernias, which may lead to ulceration of the
delayed by months or even years [30]. In certain stomach mucosa or even to its perforation [9].
cases, diaphragmatic rupture occurs sometime The overlapping of gastrointestinal, cardiolo-
after the event [25]. Post-traumatic hernias are gical and pulmonary symptoms is quite common
associated with a higher mortality rate and are in these patients [24]. In one of the cases, the
more often an indication for surgical treatment co-occurrence of pronounced gastrointestinal,
[24, 30]. This was also confirmed by one of the cardiological and pulmonary manifestations was
cases presented above. noted and should be treated as an alarm group of
On the other hand, in one of the cases, a large symptoms requiring a rapid response and emergen-
diaphragmatic hernia was discovered by accident cy surgical treatment. This patient was disqualified
basing on abnormalities in a chest X-ray while the from surgery due to multiple coexisting risk factors
patient was being treated for drug-induced bra- and died after a few months’ time. The remaining
dycardia. Heart arrhythmias in the form of atrial cases concerned people over the age of 90. In these
fibrillation were found in two of the patients, patients, hernias had a long documented course
while chronic heart failure was found in all of and their symptoms were subdued and non-speci-
them. However, this is more likely to be due to fic. However, analysing these cases, it seems that in
the advanced age of the study group. Tachycardia older people the prognosis will be less favourable,
(> 120/min) was observed in only one of the particularly with coexisting disorders.
patients. Chest pain was reported by 3 patients, The observed population ageing in developed
but in 2 of the cases, the pain was retrosternal, countries will lead to an increase in the detec-
described as distending and associated with food tion of large hiatal hernias. Such a diagnosis in
intake, and in the third case, it was pleural pain 80-year-olds, and all the more in 90-year-olds,
related to chest wall injury. Although most of will have a significant effect on the further quality
the literature indicates a prevalence of gastroin- of their lives, as well as worse future survival
testinal symptoms and specifically symptoms of prognosis. A great majority (78%) of deaths is
gastroesophageal reflux disease and oesophagitis, pronounced in type III and IV hiatal hernias and
some reports describe cases in which cardiologi- is correlated with coexisting diseases [13]. This
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Advances in Respiratory Medicine 2019, vol. 87, no. 1, pages 54–62
is why a relatively early detection of disturbances Neth J Med. 2012; 70(5): 222–226, indexed in Pubmed: 22744923.
18. Furukawa N, Iwakiri R, Koyama T, et al. Proportion of reflux
is important, while it is still possible to carry out esophagitis in 6010 Japanese adults: prospective evaluation by
the procedures laparoscopically. The problem endoscopy. J Gastroenterol. 1999; 34(4): 441–444, indexed in
particularly concerns older women with thoracic Pubmed: 10452674.
19. Cole TJ, Turner MA. Manifestations of gastrointestinal disease on
cage deformities. chest radiographs. Radiographics. 1993; 13(5): 1013–1034, doi:
10.1148/radiographics.13.5.8210587, indexed in Pubmed: 8210587.
Conflict of interest 20. Boushey RP, Moloo H, Burpee S, et al. Laparoscopic repair of
paraesophageal hernias: a Canadian experience. Can J Surg.
2008; 51(5): 355–360, indexed in Pubmed: 18841230.
The authors declare no conflict of interest. 21. Higashi S, Nakajima K, Tanaka K, et al. Laparoscopic anterior
gastropexy for type III/IV hiatal hernia in elderly patients. Surg
Case Rep. 2017; 3(1): 45, doi: 10.1186/s40792-017-0323-1, in-
References: dexed in Pubmed: 28321807.
22. Le Page PA, Furtado R, Hayward M, et al. Durability of giant
1. Chandrasekharan PK, Rawat M, Madappa R, et al. Congenital
hiatus hernia repair in 455 patients over 20 years. Ann R Coll
diaphragmatic hernia — a review. Matern Health Neonatol
Surg Engl. 2015; 97(3): 188–193, doi: 10.1308/003588414X140
Perinatol. 2017; 3: 6, doi: 10.1186/s40748-017-0045-1, indexed
55925060839, indexed in Pubmed: 26263802.
in Pubmed: 28331629.
23. Tam V, Winger DG, Nason KS. A systematic review and meta
2. Torfs CP, Curry CJ, Bateson TF, et al. A population-based study
-analysis of mesh vs suture cruroplasty in laparoscopic large
of congenital diaphragmatic hernia. Teratology. 1992; 46(6):
hiatal hernia repair. Am J Surg. 2016; 211(1): 226–238, doi:
555–565, doi: 10.1002/tera.1420460605, indexed in Pubmed:
10.1016/j.amjsurg.2015.07.007, indexed in Pubmed: 26520872.
1290156.
24. Testini M, Girardi A, Isernia RM, et al. Emergency surgery due
3. Horton JD, Hofmann LJ, Hetz SP. Presentation and manage-
to diaphragmatic hernia: case series and review. World J Emerg
ment of Morgagni hernias in adults: a review of 298 cases.
Surg. 2017; 12: 23, doi: 10.1186/s13017-017-0134-5, indexed in
Surg Endosc. 2008; 22(6): 1413–1420, doi: 10.1007/s00464-
Pubmed: 28529538.
008-9754-x, indexed in Pubmed: 18347869.
25. Magu S, Agarwal S, Singla S. Computed tomography in the
4. Nursal TZ, Ugurlu M, Kologlu M, et al. Traumatic diaphragma-
evaluation of diaphragmatic hernia following blunt trauma.
tic hernias: a report of 26 cases. Hernia. 2001; 5(1): 25–29,
Indian J Surg. 2012; 74(4): 288–293, doi: 10.1007/s12262-011-
indexed in Pubmed: 11387719.
0390-7, indexed in Pubmed: 23904715.
5. Cortes M, Tapuria N, Khorsandi SE, et al. Diaphragmatic her-
26. Schuchert MJ, Adusumilli PS, Cook CC, et al. The impact of
nia after liver transplantation in children: case series and re-
scoliosis among patients with giant paraesophageal hernia.
view of the literature. Liver Transpl. 2014; 20(12): 1429–1435,
J Gastrointest Surg. 2011; 15(1): 23–28, doi: 10.1007/s11605-
doi: 10.1002/lt.23977, indexed in Pubmed: 25124299.
010-1307-7, indexed in Pubmed: 20824386.
6. Johnson DA, Ruffin WK. Hiatal hernia. Gastrointest Endosc 27. Sánchez-Pernaute A, Talavera P, Pérez-Aguirre E, et al. Tech-
Clin N Am. 1996; 6(3): 641–666, indexed in Pubmed: 8803572. nique of hill’s gastropexy combined with sleeve gastrectomy
7. Kang JY. Systematic review: geographical and ethnic differences for patients with morbid obesity and gastroesophageal reflux
in gastro-oesophageal reflux disease. Aliment Pharmacol Ther. disease or hiatal hernia. Obes Surg. 2016; 26(4): 910–912, doi:
2004; 20(7): 705–717, doi: 10.1111/j.1365-2036.2004.02165.x, 10.1007/s11695-016-2076-5, indexed in Pubmed: 26864390.
indexed in Pubmed: 15379831. 28. Wilson LJ, Ma W, Hirschowitz BI. Association of obesity with
8. Dean C, Etienne D, Carpentier B, et al. Hiatal hernias. Surg hiatal hernia and esophagitis. Am J Gastroenterol. 1999;
Radiol Anat. 2012; 34(4): 291–299, doi: 10.1007/s00276-011- 94(10): 2840–2844, doi: 10.1111/j.1572-0241.1999.01426.x,
0904-9, indexed in Pubmed: 22105688. indexed in Pubmed: 10520831.
9. Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: 29. Thiam O, Konate I, Gueye ML, et al. Traumatic diaphragmatic
evaluation and surgical management. J Thorac Cardiovasc injuries: epidemiological, diagnostic and therapeutic aspects.
Surg. 1998; 115(1): 53–60; discussion 61, indexed in Pubmed: Springerplus. 2016; 5(1): 1614, doi: 10.1186/s40064-016-3291-
9451045. 1, indexed in Pubmed: 27652187.
10. Chory ET. Laparoscopic surgical treatment of paraesophageal 30. Lu J, Wang Bo, Che X, et al. Delayed traumatic diaphragma-
hiatus hernia. J Lancaster General Hospital. 2007; 2(2): 56–59. tic hernia: A case-series report and literature review. Me-
11. Mitiek MO, Andrade RS. Giant hiatal hernia. Ann Tho- dicine (Baltimore). 2016; 95(32): e4362, doi: 10.1097/
rac Surg. 2010; 89(6): S2168–S2173, doi: 10.1016/j.atho- MD.0000000000004362, indexed in Pubmed: 27512848.
racsur.2010.03.022, indexed in Pubmed: 20494004. 31. Devbhandari MP, Khan MA, Hooper TL. Cardiac compression
12. DeAlwis K, Mitsunaga EM. Sudden death due to nontraumatic following cardiac surgery due to unrecognised hiatus hernia.
diaphragmatic hernia in an adult. Am J Forensic Med Pathol. Eur J Cardiothorac Surg. 2007; 32(5): 813–815, doi: 10.1016/j.
2009; 30(4): 366–368, doi: 10.1097/PAF.0b013e318187e013, ejcts.2007.08.002, indexed in Pubmed: 17881242.
indexed in Pubmed: 19901820. 32. Narala K, Banga S, Hsu M, et al. Hiatal hernia mimicking ST
13. Sihvo EI, Salo JA, Räsänen JV, et al. Fatal complications of elevation myocardial infarction. Cardiology. 2014; 129(4): 258–
adult paraesophageal hernia: a population-based study. J Tho- 261, doi: 10.1159/000367778, indexed in Pubmed: 25402752.
rac Cardiovasc Surg. 2009; 137(2): 419–424, doi: 10.1016/j. 33. Harada K, Tamura U, Ichimiya C, et al. Left ventricular obs-
jtcvs.2008.05.042, indexed in Pubmed: 19185163. truction caused by a large hiatal hernia. Echocardiography.
14. Yoshimura M, Nagahara A, Ohtaka K, et al. Presence of verte- 2017; 34(8): 1254–1256, doi: 10.1111/echo.13563, indexed in
bral fractures is highly associated with hiatal hernia and re- Pubmed: 28497506.
flux esophagitis in Japanese elderly people. Intern Med. 2008; 34. Vanerio G. Syncope caused by huge hiatal hernia. Case Rep
47(16): 1451–1455, indexed in Pubmed: 18703854. Cardiol. 2011; 2011: 560734, doi: 10.1155/2011/560734, in-
15. Kusano M, Hashizume K, Ehara Y, et al. Size of hiatus her- dexed in Pubmed: 24826222.
nia correlates with severity of kyphosis, not with obesity, in 35. Sontag SJ. The spectrum of pulmonary symptoms due to gastro-
elderly Japanese women. J Clin Gastroenterol. 2008; 42(4): esophageal reflux. Thorac Surg Clin. 2005; 15(3): 353–368, doi:
345–350, doi: 10.1097/MCG.0b013e318037556c, indexed in 10.1016/j.thorsurg.2005.04.002, indexed in Pubmed: 16104126.
Pubmed: 18277907. 36. Sahin C, Akın F, Cullu N, et al. A large intra-abdominal hiatal
16. Fujimoto K. Review article: prevalence and epidemiolo- hernia as a rare cause of dyspnea. Case Rep Cardiol. 2015;
gy of gastro-oesophageal reflux disease in Japan. Aliment 2015: 546395, doi: 10.1155/2015/546395, indexed in Pubmed:
Pharmacol Ther. 2004; 20 (Suppl 8): 5–8, doi: 10.1111/j. 26229693.
1365-2036.2004.02220.x, indexed in Pubmed: 15575864. 37. Wachsmann JW, Kim CK. V/Q matched defect larger than hiatal
17. Loffeld RJ, Liberov B, Dekkers PEP. The changing prevalence of hernia itself. World J Nucl Med. 2015; 14(3): 202–204, doi:
upper gastrointestinal endoscopic diagnoses: a single-centre study. 10.4103/1450-1147.163255, indexed in Pubmed: 26420992.
62 www.journals.viamedica.pl