Isolated trans-hiatal colonic herniation causing gastric outlet obstruction

Introduction. There are four types of hiatus hernia, with type IV being the rarest and occurring in less than 5%. A hiatus hernia that contains only the transverse colon without the stomach and that did not arise because of a traumatic diaphragmatic defect, such as in this case is very seldom, and eight similar cases have been described in the literature so far. Case outline. A 66-year-old man presented to the emergency room with a complaint of nausea and frequent vomiting. Upon examination, the paraumbilical region was profoundly tender. Abdominal X-ray revealed a distended stomach with air-liquid levels in the right upper quadrant. Ultrasound of the abdomen showed a distended, hypotonic stomach and a suspicious solitary mass of the right kidney. Contrast enhanced computed tomography examination showed an isolated herniation of the transverse colon with its respective vascular pedicle, causing consecutive compression and obstruction of the pylorus and duodenal bulb. An open laparotomy was performed ? including repositioning of the transverse colon with omentum along with repair of the crural defect and Toupet?s fundoplication. In the same act, a right-sided radical nephrectomy was performed. The patient was discharged after 10 days without complications. Conclusion. Isolated trans-hiatal herniation of the colon presents with non-specific symptoms and in the case of acute gastric obstruction is an indication for urgent surgery. Correct diagnosis confirmed by computed tomography and adequate treatment can prevent possible complications.