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 Annals of Agricultural and Environmental Medicine 2021, Vol 28, No 1, 20–26
www.aaem.pl REVIEW ARTICLE

Hiatal hernia as a rare cause of cardiac

complications– case based review
of the literature
Karol Krawiec1,A-D,F , Marcin Szczasny1,C,F , Adam Kadej2,B,F , Małgorzata Piasecka3,B,F ,
Piotr Blaszczak1,C,F , Andrzej Głowniak4,A,C-F
1
Department of Cardiology, Cardinal Wyszynski Hospital, Lublin, Poland
2
Department of General Surgery, Cardinal Wyszynski Hospital, Lublin, Poland
3
Department of Anaesthesiology and Intensive Therapy, Cardinal Wyszynski Hospital, Lublin, Poland
4
Department of Cardiology, Medical University, Lublin, Poland
A – Research concept and design, B – Collection and/or assembly of data, C – Data analysis and interpretation,
D – Writing the article, E – Critical revision of the article, F – Final approval of article
Krawiec K, Szczasny M, Kadej A, Piasecka M, Blaszczak P, Głowniak A. Hiatal hernia as a rare cause of cardiac complications – case-based
review of the literature. Ann Agric Environ Med. 2021; 28(1): 20–26. doi: 10.26444/aaem/133583

Abstract
Introduction. Hiatal hernia (HH) is a condition which refers to the protrusion of an intraabdominal organ in the thorax cavity
throughan oesophageal hiatus of the diaphragm. Sliding HH is usually associated with non-specific symptoms, including
heartburn, regurgitation or epigastric pain. Importantly, true paraesophageal hernia may lead to cardiac compression.
Knowledge of cardiac manifestations of HH is limited.
Objective The main aim of the study is to present the rare case of a patient with gastrothorax due to hiatal hernia which
caused cardiac arrest, and to provide a literature-based review of the cardiac aspects of hiatal hernia.
Brief description of the state of knowledge. Patients with paraesophageal hernia may experience arrhythmia, including
sinus tachycardia, atrial flutter, atrial fibrillation, supraventricular extrasystole and ventricular tachycardia, as well as left
bundle branch block, atrioventricular conduction block and electrocardiographic changes in the ST-segment and T-wave.
In echocardiograph, HH may appear as an extracardiac posterior mass encroaching on the left atrial cavity, mimicking the
left atrial mass. Rarel, HH may be manifested as tension gastrothorax leading cardiac arrest. In such a case, timely diagnosis
and instant adequate treatment of the underlying condition are crucial.
Conclusions. Hiatal hernia should be considered as a possible cause of arrhythmia and changes in ST-T pattern, particularly if
symptoms occurred after a meal. Differential diagnosis of the posterior mediastinal mass or intracardiac mass should include
hiatal hernia. Gastrothorax is a rare condition associated with hiatal hernia which may lead to cardiac arrest. However, even
timely recognition and therapy of gastrothorax does not ensure a positive clinical outcome.
Key words:
Gastrothorax, hiatus hernia, cardiac arrest, acute heart failure

INTRODUCTION large defect in the phrenoesophageal membrane leading to

the herniation of stomach and other abdominal organs [1–4].
Hiatal hernia is a condition which refers to the protrusion of an Figure 1 presents classification of hiatal hernia.
intraabdominal organ or organs in the thorax cavity through There is no single definition of a massive hiatal hernia. It
an oesophageal hiatus of the diaphragm [1, 2, 3]. According to may be defined as a hernia which is bigger than 5 cm, or to
the classification based on the location of the gastroesophageal the herniation of the entire stomach into the mediastinum
junction in relation to the crural pillar, there are four types [5]. Giant hiatal hernia may also refer to a herniation of
of hiatal hernia [1, 4]. Type I is also known as a sliding hernia more than 30% or – by other authors -more than 50% of the
and is defined as a displacement of the gastroesophageal stomach [6]. Some authors indicate that the size of hernia
junction above the diaphragm. This is the most common type is not sufficient to be the sole criterion of massive hernia
of hiatal hernia which accounts for approximately 85–95% [5]. Thus, there are reports of a massive hiatal hernia which
of all hiatal hernias. Types II, III and IV are classified as true encompasses type II, III and IV [5].
paraesophageal hernias and represent about 5–15% of cases While sliding hernia is usually associated with the
of hiatal hernia. Type II is characterized by the herniation of gastroesophageal reflux disease, paraesophageal hernias may
the gastric fundus. Type III is the most common type of true lead to the obstruction, ischemia, or volvulus of the contents
paraesophageal hernias, and results from the herniation of of the hernial sac [3]. It may also cause respiratory distress due
gastric fundus and gastroesophageal junction through the to compression of the lung [5]. Large hiatal hernia may also
diaphragmatic hiatus. The hernia may enlarge, drawing other result in the displacement and compression of the heart [7].
parts of stomach into the chest [4]. Type IV results from a However, data about cardiac manifestations of hiatal hernia
Address for correspondence: Andrzej Głowniak, Department of Cardiology, Medical are scarce and mostly limited to case reports. The aim of this
University of Lublin, ul. Jaczewskiego 8, 20-090, Lublin, Poland study is to present the case of a patient with a giant hiatal
E-mail: andrzej.glowniak@gmail.com hernia which caused cardiac arrest, and to present a review
Received: 27.01.2021; accepted: 22.02.2021; first published: 08.03.2021 of the literature of the cardiological aspects of hiatal hernia.
Annals of Agricultural and Environmental Medicine 2021, Vol 28, No 1 21
Karol Krawiec, Marcin Szczasny, Adam Kadej, Małgorzata Piasecka, Piotr Blaszczak, Andrzej Głowniak. Hiatal hernia as a rare cause of cardiac complications…

Figure 1. Types of hiatal hernia

CASE STUDY operating theatre, sudden cardiac arrest in the mechanism

of pulseless electrical activity (PEA) occurred. Immediate
A 51-year-old, obese (BMI 30.86kg/m2) agricultural worker left-sided thoracotomy was performed to release the trapped
was admitted to the Emergency Department due to severe viscera, and to enable direct cardiac massage which was
epigastric pain and vomiting, following the lifting of heavy successfully performed and normal sinus rhythm restored.
fertilizer bags. Afterwards, during laparotomy, hernia content was returned
In physical examination on admission the patient was to the abdominal cavity, the hiatus hernia repaired and the
tachycardiac (150/min) with tachypneic (30/min). Blood patient transferred to the intensive care unit. Regardless of
pressure was normal 110/60 mmHg although the pulse was the effective surgical intervention, in the postoperative period
hypokinetic and jugular vein distention was present. Chest the patients experienced significant complications, including
examination revealed a dull percussion note and absence of cardiac and respiratory failure, post-cardiac arrest brain
respiratory sounds in the left haemithorax. The abdomen was injury, acute kidney injury and gastrointestinal bleeding. He
distended, with tenderness in the epigastric area. required mechanical ventilation and continuous infusion of
Electrocardiogram (ECG) displayed sinus tachycardia, catecholamines, haemodialysis, neuroprotective treatment,
intermediate heart axis, low voltage of QRS complexes, and broad-spectrum antibiotics. The patient died on day 22
incomplete right bundle branch block, q in leads II, III and aVF. after surgery due to multiple-organ failure.
Computed tomography (CT) of chest and abdomen
performed without delay revealed a giant hiatal hernia
strangulated in the chest cavity, with hernia’s gate about DISCUSSION
7 cm. The stomach was distended, twisted and significantly
(> 50%) translocated into the chest resulting in displacement Tension gastrothorax as hiatal hernia complication.
and compression of the heart. The hiatal sac included also a Tension gastrothorax is a rare and life-threating condition,
part of the duodenum and its mesentery. The portal venous which causes contralateral shift and compression of the
gas was stated and the left lung significantly compressed mediastinal structures by translocation of the stomach
(Fig. 2). into the chest cavity [8, 9]. It is usually associated with
The patient was referred for an emergency thoracotomy and congenital diaphragmatic hernia in children, or occurs due
laparotomy. Directly after transportation of the patient to the to diaphragmatic injury as a result of trauma or complication

Figure 2. Chest CT scans showing giant hiatal hernia causing massive compression of the heart
22 Annals of Agricultural and Environmental Medicine 2021, Vol 28, No 1
Karol Krawiec, Marcin Szczasny, Adam Kadej, Małgorzata Piasecka, Piotr Blaszczak, Andrzej Głowniak. Hiatal hernia as a rare cause of cardiac complications…

of some surgical procedures [10, 11]. Sporadically, tension presumably triggered by the hiatal hernia reported in the
gastrothorax may be a manifestation of hiatal hernia – as in literature.
case of the presented patient [8, 10]. Tension gastrothorax may In most cases, electrocardiographic alternation
be difficult to diagnose because its clinical manifestations, disappeared after initial stomach decompression or surgical
including dyspnea, tachycardia and hypotension, may correction of the hiatal hernia [18, 20, 21, 30–35], or after
mimic pneumothorax [9, 10]. However, contrary to the successful conservative management with dietary control
pneumothorax, in the gastrothora, bowel sounds may be and proton pump inhibitor [29]. Resolution of abnormal
auscultated over the lungs fields [9]. Patients with gastrothorax findings in ECG after management of hiatal hernia may
may also present with abdominal pain and vomiting [9]. imply a causal relationship between the hiatal hernia and
Tension gastrothorax may lead to cardiopulmonary arrest changes in the electrocardiogram pattern and rhythm.
[9, 10] which ensues due to extrinsic compression of the However, ECG repolarization disorders persistent up to
heart by the strangulated hiatal herni, which occurred in three months have been observed after successful surgery,
the presented case. possibly due to pericardial irritation [26]. Roy et al. carried
There are only few published case reports of tension out a retrospective analysis of patients with hiatal hernia for
gastrothorax complicated by cardiac arrest [8–15]. The the presence of atrial fibrillation. The authors demonstrated
majority were caused by trauma [9, 11–14], while by hiatal that 7.1% of all patients with hiatal hernia experienced atrial
hernia in only two cases by [8, 10]. Solé et al. reported thecase of fibrillation. Interestingly, the prevalence of atrial fibrillation
a 75-year-old man with chest pain, dyspnea and nausea. Minor was 17.5-fold and 19-fold higher in men and women younger
increase of troponin I with ST-segment depression in ECG than 55 years with hiatal hernia, compared to the general
suggested acute coronary syndrome. The patient experienced population [36].
cardiopulmonary arrest, recovering after resuscitation, but Although the exact mechanism of changes in
with persistent hypotension. Echocardiogram did not show electrocardiogram related to the hiatal hernia is not well
any significant abnormalities. Chest CT revealed a giant understood, some hypotheses have attempted to explain
hiatal hernia causing cardiac displacement, and compression these findings. Schilling et al. suggested that persistent
of the left lobar bronchus [8]. Shoij et al. presented the case of a compression of the left atrium by the hiatal hernia may
60-year-old man with suspected myocardial infarction as an result in an area of relative ischemia and conduction block,
underlying condition of cardiopulmonary arrest. However, causing reentry [31]. Another explanation of changes in
in echocardiogram there were no abnormalities, and further electrocardiogram may be the stimulation of the vagal
imaging studies revealed tension gastrothorax due to a hiatal nerve by pressure from the hiatal hernia [31, 37]. Increased
hernia as the actual cause of cardiac arrest [10]. Thus, it vagal tone may precipitate the onset of tachycardia in the
appears that tension gastrothorax may mimic acute coronary mechanism similar to that in bradycardia-tachycardia
syndrome and should be considered as a potential reason of syndrome [29]. Kounis et al. presumed that the increase in
cardiac arrest. direct or indirect pressure exerted on the global surface of
Diagnosis of tension gastrothorax should be based on the heart appears to be the cause of the electrical alternation
clinical signs and symptoms, although timely imaging studies observed in electrocardiography of patients with increased
are essential for the appropriate diagnosis. Radiological signs intrathoracic pressure, including those with hiatal hernia
suggesting gastrothorax include the presence of abdominal [38]. Maruyama et al. implied that mechanical contact and
organs in the thorax, elevated diaphragm, compressive irritation on the left atrium or pulmonary veins by the hiatal
atelectasis, mediastinal displacement, visible fluid levels, hernia may contribute to the ectopic firing leading to the atrial
and/or the presence of gas bubbles in the chest [12, 16]. In the fibrillation [39]. Roy et al. suggested that since hiatal hernia is
current case, a CT scan of the abdomen and chest revealed the related to reflux oesophagitis, the inflammation may extend
presence of massive hiatal hernia which compressed the heart to the surrounding organs, including the left atrium,and lead
to the anterior thoracic wall, and constricted the left lung. to tachyarrhythmia due to mechanical or chemical/neural
The emergency initial management of gastrothorax impact mediated through the vagal or sympathetic nervous
included decompression of the stomach by the placement system [36]. Basir et al. hypothesized that ST elevation may
of a nasogastric or orogastric tube [10]; laparotomy or be related to torsion or compression of the epicardial artery
thoracotomy was the treatment of choice. In the presented from direct pressure from the hiatal hernia [21]. In patients
case, the patient required both. Similar management was without hiatal hernia but with extreme abdominal distension
needed in a patient reported by Shoji et al. [10]. However, and hemi-diaphragm elevation, it has been also suggested
according to the literature, some patients with gastrothorax that elevation of ST in the electrocardiograph may result from
complicated by cardiac arrest underwent solely laparotomy the mechanical compression or transient vasospasm of one
[13, 14] or thoracotomy [9, 11]. During the surgery, the or more coronary arteries from the diaphragm impinging
anatomical position of the organs is restored and the hiatus on the myocardium from severe abdominal distention [40].
hernia repaired [10]. It should be highlighted that laparoscopy Patients with a large hiatal hernia may experience
can increase the pressure in the abdominal cavity, thus it arrhythmias, including sinus tachycardia, atrial flutter,
should be performed with caution [10]. atrial fibrillation, supraventricular extrasystole and
ventricular tachycardia, as well as left bundle branch block,
Hiatal hernia and changes in electrocardiogram. Changes atrioventricular conduction block and electrocardiographic
in the electrocardiogram pattern and rhythm have been changes in the ST-segment and T-wave. There is a need
observed in patients with hiatal hernias [17–35]. However, to consider hiatal hernia as a reason for the abnormal
the linkage between these conditions has not been fully electrocardiogram pattern and rhythm, particularly in
elucidated. Table 1 presents a summary of selected case reports patients with clinical symptoms that occurred after meals
of patients with abnormal findings in electrocardiogram, or in the supine position.
Annals of Agricultural and Environmental Medicine 2021, Vol 28, No 1 23
Karol Krawiec, Marcin Szczasny, Adam Kadej, Małgorzata Piasecka, Piotr Blaszczak, Andrzej Głowniak. Hiatal hernia as a rare cause of cardiac complications…

Table 1. Selected case reports of patients with hiatal hernia and abnormal findings in ECG
Case Gender Age Symptoms ECG ECHO X-ray CT Surgical method
Schumer W. Dyspnea, Left bundle branch Cardiomegaly, large mass
M 73 No information Large HH Not described
2017 [17] chest pain block behind the heart
Type III giant HH
Hokamaki J. Chest pain, Mass compressing Large shadow overlapping Nissen fundoplication,
F 79 ST-T changes compressing the
et al. 2005 [18] vomiting LA, LV, IVC cardiac silhouette Hill’s method
heart and IVC
Zanini G. et al. Non-operative
F 78 Dyspnea ST-T changes Mass in LA Normal No information
2009 [19] treatment
LV distortion with
Gard J.J. et al. Abdominal Large HH, gastric
M 73 ST-T changes asynchronous Large HH Nissen fundoplication
2011 [20] pain volvulus
contraction
Basir B. et al. Large HH, gastric
M 86 Nausea ST-T changes Normal Large HH Nissen fundoplication
2013 [21] volvulus
Abdominal Mass compressing
Narala K. et al. pain, LV, dyskinesis Left lung compression with
M 72 ST-T changes Large HH Gastropexy
2014 [22] presyncopal of inferior and a radiopaque left lung field
episodes lateral LV
Abdominal
Rossington J.A. Perforated volvulus
F 66 pain, ST-T changes Collapse of LA No information Laparoscopy
et al. 2014 [23] of the stomach; HH
vomiting
HH, pneumopericardium, Type I HH,
Kakarala K. Chest pain, Thoracotomy,
M 41 ST-T changes No information pleural thickening or fluid pneumopericardium,
et al. 2015 [24] dyspnea laparotomy
in the left base pericardial effusion
Gastric bubble and air-fluid Large HH
Harada K. et al. Mass compressing
M 76 Chest pain ST-T changes level overlapping cardiac compressing LA Not described
2017 [25] LA and LV
silhouette and LV
Rubini- Diastolic
Dyspnea,
Gimenez M. F 61 ST-T changes dysfunction, high No information Giant HH Laparoscopy
chest pain
et al. 2019 [26] PAP
Mass compressing
Large HH
Arvind A. et al. Chest pain, LA and LV causing
F 87 ST-T changes No information compressing the Toupet fundoplication
2019 [27] nausea tamponade
heart
physiology
Cardiomegaly, a
Gürgün C. et al. dome shaped air level
F 76 Dyspnea Atrial fibrillation Normal No information Laparoscopy
2002 [28] overlapping cardiac
silhouette
Duygu H. et al. Non-operative
F 79 Chest pain Atrial fibrillation TR, MR, high PAP No information HH
2008 [29] treatment
Widening of the
Cristian D.A. Mass compressing mediastinum, large
F 77 Dyspnea Atrial fibrillation No information Nissen fundoplication
et al. 2015 [30] LA, MR shadow overlapping the
heart
Schilling R.J. Hearth Atrial flutter with 2:1
M 72 Normal Large mediastinal mass No information Not described
et al. 1998 [31] palpitations AV block
Failure to Cardiomegaly, a large
Patel A. et al
F 80 thrive and Atrial flutter High PAP lucency involving the mid Large HH Gastropexy
2014 [32]
weakness and lower hemi-thoraces
Supraventricular
Weakness, extrasystole, atypical
Tursi A. et al. Giant gastric HH Nissen-Rossetti
F 75 dysphagia, right bundle branch No information No information
2001 [33] compressing LA fundoplication
heartburn block pattern, and
inferior axis
Mass compressing
Gnanenthiran Ventricular
M 78 Syncope LA, dyskinesis No information No information Laparoscopy
S.R. et al. [34] tachycardia
of LV
HH compressing
Gleadle J. et al. Sinus tachycardia,
F 65 Vomiting and displacing the Very large HH No information Not described
1989 [35] ST-T changes
heart
Sinus tachycardia,
low voltage of Giant HH
Abdominal Thoracotomy,
Present report M 51 QRS complexes, No information No information compressing and
pain laparotomy
incomplete right displacing the heart
bundle branch block
F – female; HH – hiatal hernia; IVC – inferior vena cava; LA – left atrium; LV – left ventricle; M – male; MR – Mitral regurgitation; PAP – pulmonary arterial pressure; TR -Tricuspid regurgitation
24 Annals of Agricultural and Environmental Medicine 2021, Vol 28, No 1
Karol Krawiec, Marcin Szczasny, Adam Kadej, Małgorzata Piasecka, Piotr Blaszczak, Andrzej Głowniak. Hiatal hernia as a rare cause of cardiac complications…

Hiatal hernia and echocardiography. Hiatal hernia may be additional imaging, including computed tomography or
visualized in the transthoracic echocardiogram while it is magnetic resonance imaging [63].
encroaching on the posterior part of the left atrium and left
atrioventricular junction [41]. Hiatal hernia is usually seen Hiatal hernia mimicking cardiac tamponade. Hiatal hernia
as an extracardiac posterior mass encroaching on the left has been reported as a rare cause of cardiac compression
atrial cavity, mimicking a left atrial mass on transthoracic mimicking cardiac tamponade due to a distended stomach
echocardiography [25, 42–54]. However, this may not be after coronary artery bypass and post-type A aortic
obviously apparent since its visualization relates to the dissection repair surgery [64–66]. It has been suggested that
imaging plane and respiratory fluctuation [41]. It has been patients with hiatal hernia may benefit from a prophylactic
observed that hiatal hernia is seen in its maximal dimension nasogastric tube placement prior cardiac surgery, limiting
while the left atrium is imaged in a posterior plane. On the the risk of gastric stasis, vomiting, aspiration pneumonia and
other hand, while the eft atrium is imaged in an anterior haemodynamic compromise [64, 65]. Prompt decompression
plane, the hiatal hernia appears to be progressively smaller of the dilated stomach results in the improvement of the
or even absent on transthoracic echocardiography [55]. haemodynamic status of patient and resolution of the
D’Cruz et al. described features of hiatal hernia commonly symptoms [65, 66].
seen on the echocardiograp, including: Extra-pericardial pathologies including hiatal hernia
• a large ill-defined amorphous solid mass apparently should be considered in patients’ post-cardiac surgeries
filling all or most of the left atrial chamber in the apical with symptoms suggesting cardiac tamponade without its
4-chamber view (imaging the posterior atrial plane), which objective evidence on echocardiography [64, 65].
sometimes may extends across the atrial septum into the
adjacent right atrial space; Hiatal hernia and syncope. In the literature there are several
• a large convex poorly-demarcated mass impinging on the reports of a syncope due to a huge hiatal hernia. Saito et al.
posterior left atrial wall, atrioventricular junction, or even reviewed nine cases of syncope related to hiatal hernia from
occasionally on the postero-basal left ventricular wall in the literature between January 1995 – August 2016 [67].
the parasternal or apical long-axis views; Most of the reported episodes of syncope occurred after
• paradoxical motion of the left ventricular wall if there is eating an unusually large meal. It has been suggested that
its encroachment; compression of the enlarged stomach on the left atrium may
• respiratory fluctuation in degree of encroachment of the be the cause of syncope [68]. Haemodynamic instability due
hiatal hernia mass on the left atrium; to the cardiac compression may result in a decreased preload
• normal sonolucency of the descending thoracic aorta in the and cardiac output which lead to syncope [69]. Differential
apical 4-chamber and long-axis views partly or completely diagnosis of left atrium compression should also include
obscured by the large echogenic hiatal hernia [55]. tumours and thrombosis; therefore, further imaging studies
may be necessary for final recognition [70]. Maekawa et al.
Oral ingestion of a carbonated beverage may lead to reproduced a syncopal attack in their patient using a water
visualization of swirling echodensities in the mass or pouring test through a nasogastric tube [71]. Hiatal hernia
distinct echo-free space replacing a substantial portion of should therefore be considered in the differential diagnosis
the original ‘mass’, facilitating the differential diagnosis of postprandial syncope.
between a true left atrial mass and a hiatal hernia on
transthoracic echocardiogram [42, 50, 55, 56]. The use of
intravenous echocardiographic contrast may also be helpful CONCLUSIONS
in establishing the diagnosis of hiatal hernia [56]. Smelly
et al. suggested that the combination of an oral ingestion of In conclusion, hiatal hernia should be considered as a reason
carbonated beverage mixed with echocardiographic contrast of arrhythmia and changes in the ST-T pattern, particularly
media should better delineate extracardiac structures [56]. if clinical symptoms occurred after a meal. Differential
Hiatal hernia may be difficult to visualize in the diagnosis of posterior mediastinal mass lesions or intracardiac
transesophageal echocardiography because of the inability masses should include hiatal hernia. Gastrothorax is a rare
to obtain adequate images [57]. However, Frans et al. condition associated with hiatal hernia which may lead to
suggested that on the transesophageal echocardiography, cardiac arrest. Early diagnosis based on imaging studies
hiatal hernia may be seen as a posterior, mass-like lesion enables appropriate management. However, even timely
with microbubbles, and thick inner lining resembling the recognition and therapy of gastrothorax does not ensure a
stomach mucosa [58]. positive clinical outcome.
There have been several papers reporting left atrial
compression with haemodynamic collapse and heart failure
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26 Annals of Agricultural and Environmental Medicine 2021, Vol 28, No 1
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