Breaking Boundaries: A Case Report of Giant Hiatal Hernia Housing Pancreas, Stomach, Small Bowel, and Colon

Hiatal hernia (HH) is defined as the protrusion of abdominal contents through the esophageal hiatus of the diaphragm into the mediastinum. They are classified into categories I-IV. Type I, known as the sliding hernia, accounts for up to 90% of HH cases and are typically managed medically. Types II-IV combined account for less than 15% of HH cases. Types II-IV HH often require surgical repair, especially when symptomatic, due to the risk of complications such as gastric volvulus, obstruction, or strangulation. Furthermore, pancreatic herniation in a type IV HH has been shown to cause acute pancreatitis. We present the case of a 84-year-old female patient with gastroesophageal reflux disease (GERD) and type IV HH who presented with a three-day history of chest pain, abdominal pain, nausea, and vomiting. Urgent abdominopelvic computed tomography (CT) revealed a large HH containing the entire stomach, portions of the duodenum, colon, small bowel loops, and almost the entire pancreas - a combination that is rarely seen. The patient's symptoms resolved with ondansetron, fentanyl, and fluids, and she was discharged home from the ED with recommendations for gastroenterology follow-up. Although surgical management is considered definitive repair for type IV HH, this case highlights the possibility of non-operative medical management in chronic cases where the patient does not exhibit signs of ischemia, obstruction, volvulus, strangulation, or incarceration of the hernia. This case also highlights the importance of considering HH as a potential cause of chest pain, abdominal pain, nausea, and/or vomiting, especially in those with a history of GERD and already existing HH.