Hiatus Hernia: A Rare Cause of Acute Pancreatitis

Abstract

Hiatal hernia (HH) is the herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. A giant HH with pancreatic prolapse is very rare and its causing pancreatitis is an even more extraordinary condition. We describe a case of a 65-year-old man diagnosed with acute pancreatitis secondary to pancreatic herniation. In these cases, acute pancreatitis may be caused by the diaphragmatic crura impinging upon the pancreas and leading to repetitive trauma as it crosses the hernia; intermittent folding of the main pancreatic duct; ischemia associated with stretching at its vascular pedicle; or total pancreatic incarceration. Asymptomatic hernia may not require any treatment, while multiple studies have supported the recommendation of early elective repair as a safer route in symptomatic patients. In summary, though rare, pancreatic herniation should be considered as a cause of acute pancreatitis. A high index of suspicion for complications is warranted in cases like these.

A Rare Case of Pancreatitis From Pancreatic Herniation

“…Hiatal hernias are more common in Western populations, hypothesized to stem from lower fiber intake leading to constipation, straining, and unnaturally raised intra-abdominal pressures [2]. Furthermore, pregnancy, ascites, obesity and trauma may all increase intra-abdominal pressure and can contribute to the development of hiatal hernias [3]. Hiatal hernias are classified into the following categories depending on the extent of herniation and the position of the gastroesophageal junction: sliding hernias (type I), paraesophageal hernias (type II), mixed sliding and paraesophageal hernia (type III), and herniation of additional organs (type IV) [4,5].…”

“…Table 1 [3,[7][8][9][10][11][12][13][14][15] lists the cases of acute pancreatitis from pancreatic herniation in hiatal hernias from published literature. All cases were diagnosed based on exclusion of other etiologies for acute pancreatitis.…”

“…All cases were diagnosed based on exclusion of other etiologies for acute pancreatitis. The rarity of these cases may be attributable to the fact that the head of the pancreas and the duodenum are anchored by the ligament of Treitz in the retroperitoneum, thereby preventing trans-hiatal herniation of the pancreas [3,7].…”

Acute Pancreatitis Associated with Diaphragmatic Hernia in an Adult

“…Historically, patients were immediately treated with hiatal hernia repair. 2 Whereas, some recent reports 3,6,8 indicate that patients who have failed surgery due to high surgical risk or patient rejection have been successfully treated with supportive care (e.g., intravenous fluid supplementation, analgesia, early enteral feeding). However, in severe cases related to incarceration, perforation, or unresponsiveness to medical therapy, surgical management should be performed.…”

Transhiatal Herniation of the Pancreas: A Rare Cause of Acute Pancreatitis

“…1 In contrast, more recent cases, including ours, have been successfully managed with supportive care (e.g., intravenous fluid supplementation, analgesia, early feeding) due to perceived elevated surgical risk or patient refusal. 8,9 However, severe cases involving incarceration, perforation, or unresponsiveness to medical therapy should be managed surgically. The rate of recurrence appears to be low, so the role of elective surgical reduction is unclear.…”