Ammad Chaudhary, MD1, Hamna Fahad, MD1, Umer Farooq, MD2, Abdallah El Alayli, MD3, Muhammad Raheel Awan, MD4, Eyad Z. Gharaibeh, MD3, Jonathan Prostak, MD1 1Henry Ford Hospital, Detroit, MI; 2Rochester General Hospital, Rochester, NY; 3Saint Louis University, St. Louis, MO; 4Carle Foundation hospital, Urbana, IL
Introduction: Hiatal hernia (HH) is the protrusion of abdominal organs into the mediastinum through the diaphragmatic esophageal hiatus. Type III HH is when both the fundus and gastroesophageal junction herniate through the hiatus. HH usually remains asymptomatic and sometimes is difficult to diagnose due to its various clinical presentations, with the most common being gastroesophageal reflux. However, there are some unusual presentations that could be life-threatening. We are reporting a case of a woman with cardiac dysfunction due to left atrial compression by a large HH.
Case Description/Methods: A 92-year-old female with a past medical history of a medium-sized hiatal hernia (HH) presents with recurrent episodes of syncope occurring immediately after heavy meals for the past 4 weeks. The patient denies experiencing any prodromal symptoms, bowel/bladder incontinence, tongue biting, or seizure-like activity. On presentation, the patient was hemodynamically stable, and orthostatic testing was negative. The physical exam was unremarkable. The EKG and cardiac telemetry results were also unremarkable. Lab work showed a baseline anemia (Hb: 8g/dl). A CT brain scan did not reveal any acute changes. A CT scan of the chest, abdomen, and pelvis showed a large type 3 HH, with a largely intrathoracic stomach adjacent to the left atria (LA) without gastric outlet obstruction.
Discussion: Recurrent syncope in patients with a history of HH should prompt consideration of deglutition syncope as a potential cause. The differential diagnosis of syncope is broad, including neurological and cardiovascular causes. The presence of precipitating factors can aid in the diagnosis. Deglutition syncope can be either a neurally mediated syncope triggered by vagal nerve stimulation during swallowing or caused by pressure on the left atrium (LA) due to the HH. In this case, the patient did not exhibit orthostatic hypotension, arrhythmias, or seizures. However, the history of HH and symptoms occurring after large meals led to the hypothesis of deglutition syncope. In our patient, the size and location of the HH resulted in postprandial cardiogenic syncope due to pressure on the LA, which compromised cardiac output. Due to poor surgical candidacy and the patient's preference, the patient was discharged with proton pump inhibitors and advised to eat small, frequent meals. The patient has been compliant with these recommendations and has not experienced any recurrence of syncope.
Figure: CT scan of the Hiatal Hernia (HH) pressing against the left atrium (LA)
Ammad Chaudhary indicated no relevant financial relationships.
Hamna Fahad indicated no relevant financial relationships.
Umer Farooq indicated no relevant financial relationships.
Abdallah El Alayli indicated no relevant financial relationships.
Muhammad Raheel Awan indicated no relevant financial relationships.
Eyad Gharaibeh indicated no relevant financial relationships.
Jonathan Prostak indicated no relevant financial relationships.
Ammad Chaudhary, MD1, Hamna Fahad, MD1, Umer Farooq, MD2, Abdallah El Alayli, MD3, Muhammad Raheel Awan, MD4, Eyad Z. Gharaibeh, MD3, Jonathan Prostak, MD1. P1392 - Burping, Fainting, and Laughing: The Hilarious Tale of a Hungry Heart, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.