Virginia Research Day 2025

Medical Student Research Case Reports

23 Severe Pulmonary Compromise Induced by a Massive Type IV Hiatal Hernia: A Case Report of a Rare Presentation Requiring Medical and Procedural Management

Pranav N. Yanambakkam, OMS-III; Shaunak S. Digambar, OMS-III; Dr. Adam Varbanoff, DO Corresponding author: pyanambakkam@vcom.edu

Edward Via College of Osteopathic Medicine - Virginia Campus Smyth County Community Hospital, Marion, Virginia

Hiatal hernias occur when abdominal organs protrude through the diaphragm's esophageal hiatus into the chest, with the majority classified as Type I, which are usually asymptomatic. Type IV hiatal hernias are rare, involving herniation of multiple abdominal organs, including the stomach, colon, or pancreas, into the thoracic cavity. They are typically long-standing and gradually develop over the course of several years. While patients with hiatal hernias commonly present with mild GI symptoms, this case is unique for its rare manifestation of severe respiratory compromise caused by a massive Type IV hernia. This report details an 85-year-old female with acute hypoxemic respiratory failure resulting from a Type IV hiatal hernia compressing lung parenchyma. An 85-year-old woman presented to the Emergency Department with severe shortness of breath, cough, and hypoxemia, requiring 15 L of supplemental oxygen. Her medical history included hypertension, arthropathy, and venous stasis ulcers. Initial imaging with chest X-ray and CT scan revealed a massive hiatal hernia involving the entire stomach and a portion of the pancreas within the thoracic cavity, compressing both lower lung lobes. Additionally,

she was found to have right upper lobe pulmonary emboli, which further contributed to her respiratory distress. Despite high-flow oxygen, her respiratory requirements fluctuated between 5-12 L. Treatment included anticoagulation for her pulmonary emboli and antibiotics for concurrent pneumonia. A thoracentesis was performed to alleviate pleural effusion, resulting in the removal of 900 mL of fluid. Surgical repair was declined due to the patient’s comorbidities. This case emphasizes the unusual pulmonary complications that can arise from massive Type IV hiatal hernias. Such hernias are typically identified due to gastrointestinal symptoms, such as heartburn, reflux, or dysphagia. Respiratory distress as a primary manifestation is rare, often occurring only when large portions of abdominal organs significantly displace thoracic structures. The patient’s acute respiratory failure was driven by the mechanical compression of her lungs by the herniated stomach and pancreas, exacerbated by pleural effusions and pulmonary emboli. While literature supports that laparoscopic repair of large hiatal hernias is generally safe in

elderly patients, surgery was denied in this case due to its potential complications. This case highlights the need for a multidisciplinary approach, involving pulmonology, cardiology, and thoracic surgery, in managing complex scenarios where hernia-related mass effects impact pulmonary function. This report underscores the rare but severe potential for respiratory compromise in massive Type IV hiatal hernias. Timely recognition of hernia-induced pulmonary issues is crucial for effective management. While surgical intervention can alleviate mechanical compression, patient-specific factors such as age and comorbidities must guide the decision-making process. In this case, conservative management, supported by thoracentesis to relieve pleural effusion, was effective in stabilizing the patient. This report illustrates the need for awareness of atypical presentations of hiatal hernias and emphasizes the value of a multidisciplinary approach in managing severe respiratory complications from large hiatal hernias.

115 2025 Research Recognition Day