Iatrogenic Gastric Perforation Following Emergency Endoscopic Decompression for Obstructive Shock Caused by an Incarcerated Hiatal Hernia: A Case Report

Hiatal hernias are a common condition, particularly in the elderly. While often asymptomatic, they can lead to life-threatening complications such as incarceration, strangulation, and gastric volvulus. Obstructive shock due to cardiac compression is a rare but critical presentation. We present the case of a 77-year-old Japanese man with a history of renal transplantation who was admitted for conservative management of an incarcerated hiatal hernia. On the second day of admission, he developed profound shock, requiring ICU admission. A malpositioned nasogastric tube had failed to decompress the stomach, which was twisted due to volvulus. Point-of-care ultrasound and computed tomography confirmed a massive paraesophageal hernia causing severe cardiac compression, leading to a diagnosis of obstructive shock. An emergency endoscopic decompression was performed due to refractory shock and the inability to reposition the gastric tube. While initial gastric suction resulted in immediate hemodynamic improvement, the procedure was complicated by iatrogenic gastric perforation, leading to recurrent shock. After stabilization with conservative management, definitive laparoscopic hernia repair was performed on day 11 and he was eventually discharged home. Incarcerated hiatal hernia can cause life-threatening obstructive shock. While immediate gastric decompression is crucial, endoscopic intervention carries a significant risk of perforation due to the ischemic and fragile gastric wall. If endoscopy is deemed unavoidable for life-saving decompression, it should be limited to minimal suction to stabilize the patient for definitive surgical repair.