A 64‐year‐old woman with a history of Nissen fundoplication for gastroesophageal reflux disease presented with periumbilical abdominal pain that radiated to her back. The pain was associated with nausea. On physical exam she exhibited mild epigastic tenderness. The remainder of the exam was unremarkable. The patient did not use alcohol. Serology was remarkable for a lipase of 813. The levels for alkaline phophatase, total and direct bilirubin, calcium, and fasting lipids were all within normal limits. She was diagnosed with acute pancreatitis and admitted to the general medical floor. She was treated with intravenous fluids, antiemetics, and pain medications. A CT of the abdomen was ordered and revealed a normal head and body of the pancreas. However, the CT also revealed a hiatal hernia containing the tail of the pancreas as well as a portion of the gastroesophageal junction. The following day the patient's symptoms resolved without further intervention and she tolerated a liquid diet. Lipase levels normalized. She was safely discharged home with a surgical follow‐up for evaluation for hernia repair.
There are four types of hiatal hernias. Type IV hiatal hernias are the most rare and involve displacement of the stomach and another organ, most commonly the colon or small intestine. There are case reports of hernias that contain a portion of the pancreas. Most reports are in the pediatric literature and involve congenital diaphragmatic hernias. Interestingly, there are only a few reports of a type IV hiatal hernia containing part of the pancreatic as the cause of acute pancreatitis. The mechanism of herniation requires loosening of the transverse mesocolon that in hand permits mobilization and twisting of the pancreas into the hernia sac. It is suggested that pancreatitis is caused by ischemia that is induced by stretching of the pancreas and sometimes obstruction of the pancreatic ducts associated with the twisting. The pancreas may spontaneously revert to a normal position and coincide with improvement in symptoms, as illustrated in this case.
Pancreatitis is a common disease entity cared for by hospitalists. Therefore, it is important that hospitalists are aware of the common and the uncommon etiologies of pancreatitis, including paraesophageal pancreatic herniation.
To cite this abstract:Gunderson H. A New Twist on Pancreatitis. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 487. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-new-twist-on-pancreatitis/. Accessed April 2, 2020.