Covert presentation of strangulated hiatus hernias after cardiac surgery: a note of caution.

FIGURE 1. Computed tomographic scan showing a correctly positioned nasogastric tube and no radiologic evidence of mesenteric strangulation or ischemia. CLINICAL SUMMARIES Case 1 An 81-year-old woman with two-vessel coronary disease and preserved left ventricular function underwent elective off-pump coronary surgery to the posterior descending and left anterior descending coronary arteries. A preoperative chest radiograph was suggestive of hiatus hernia, and the patient took a proton pump inhibitor for dyspepsia. The initial postoperative course was uneventful and she was extubated within 12 hours. A chest x-ray film after chest drain removal showed a distended hiatus hernia, which was subsequently partially decompressed with a nasogastric tube. Over the next 24 hours, respiratory failure, lactic acidosis, and renal failure developed without abdominal symptoms or signs. Transesophageal echocardiography demonstrated good biventricular function and no pericardial collection. White cell count was within normal ranges and the amylase level was mildly raised (311 U/mL). A computed tomographic scan demonstrated a correctly positioned nasogastric tube and no radiologic evidence of mesenteric strangulation or ischemia (Figure 1). A general surgical opinion was obtained and laparotomy was deemed not indicated. Despite ventilation support, hemofiltration, and later vasoconstrictor support, the patient’s condition deteriorated with escalating lactic acidosis. She died of multiorgan failure. At autopsy, an incarcerated sliding hiatus hernia was found with a gangrenous intrathoracic component strangulated around a congenital band between the first part of the duodenum and the gastric fundus.