AJR 2001; 177:373-374
© American Roentgen Ray Society
Hiatal Hernia with Pancreatic Volvulus
A Rare Cause of Acute Pancreatitis
Patrick Chevallier1,
Emmanuel Peten2,
Cyril Pellegrino1,
Johanna Souci1,
Jean Paul Motamedi1 and
Bernard Padovani1
1
Department of Radiology, Centre Hospitalier
Régional et Universitaire de Nice,
Hôpital Archet II, 151 route de Saint Antoine
de Ginestière, BP 3079, 06202 Nice cedex 3,
France.
2
Department of Hepatogastroenterology, Centre Hospitalier
Régional et Universitaire de Nice,
Hôpital Archet II, BP 3079, 06202, Nice cedex
3, France.
Received August 2, 1999;
accepted after revision February 7, 2001.
Address correspondence to P. Chevallier.
Introduction
The possibility of migration of the pancreas through a diaphragmatic
hernia, although rare, has been well described in the literature
[1,2,3,4,5].
On the other hand, acute pancreatitis complicating a diaphragmatic hernia in
the same scenario is rare
[3,4,5].
We describe in this report a patient presenting with acute pancreatitis caused
by a pancreatic volvulus through a large hiatal hernia. To our knowledge, this
mechanism has never been shown before on imaging.
Case Report
A 70-year-old man was hospitalized for severe intermittent epigastric pain
associated with a 10-kg weight loss over 2 months. Laboratory workup revealed
amylase and lipase levels that were elevated three times above normal,
suggesting acute pancreatitis. A chest radiograph showed a voluminous hiatal
hernia (Fig. 1A), whereas
abdominal sonography was unremarkable. Endoscopic retrograde
cholangiopancreatography was performed and showed an obstruction of the main
pancreatic duct between the junction of the pancreatic head and isthmus,
suggesting a neoplastic obstruction at this level
(Fig. 1B). An enhanced CT scan
did confirm the presence of a large hiatal hernia along with a transverse
torsion of the pancreas leading to a folding at the level of the pancreatic
isthmus. Thus, whereas the head of the pancreas was in its anatomic position,
the tail and body were situated in the retrocrural space, with a normal
left-to-right orientation. The anterior surface of the body-tail portion of
the pancreas was oriented cranially and posteriorly, with the splenic artery
running anteriorly (Figs. 1C
and 1D). However, a CT scan did
not show evidence of either a tumor or acute pancreatitis, and a provisional
diagnosis of a body-tail pancreatic rotation around the transverse pancreatic
axis was made. The clinical picture and the biologic abnormalities were
resolved over 4 days, and the whole pancreas was shown by repeated enhanced CT
scan on the seventh day to be in its anatomic position
(Fig. 1E). Fifteen days later,
the patient underwent surgical reduction of his hiatal hernia without
complication. During the operation, the pancreas was situated in its normal
position. Perioperative biopsy samples obtained at the levels of the
pancreatic isthmus, body, and tail did not reveal the presence of any
neoplastic process. Eighteen months later, the patient remained
asymptomatic.
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Fig. 1A. —70-year-old man who presented with volvulus of head and tail
of pancreas that was herniated through esophageal hiatus, which caused acute
pancreatitis. Chest radiograph shows migration of bowel gases
(arrows) inside thorax through hiatal hernia.
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Fig. 1B. —70-year-old man who presented with volvulus of head and tail
of pancreas that was herniated through esophageal hiatus, which caused acute
pancreatitis. Endoscopic retrograde cholangiopancreatogram shows tapering
obstruction in main pancreatic duct between junction of pancreatic head and
isthmus (arrow), despite excellent visualization of some secondary
branches.
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Fig. 1C. —70-year-old man who presented with volvulus of head and tail
of pancreas that was herniated through esophageal hiatus, which caused acute
pancreatitis. Initial axial CT scan shows head of pancreas in its normal
anatomic position.
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Fig. 1D. —70-year-old man who presented with volvulus of head and tail
of pancreas that was herniated through esophageal hiatus, which caused acute
pancreatitis. Initial axial CT scan shows body—tail portion of pancreas
in thorax (curved arrow), volvulated through hiatal hernia. Splenic
artery (straight arrow) runs anteriorly along pancreatic portion.
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Fig. 1E. —70-year-old man who presented with volvulus of head and tail
of pancreas that was herniated through esophageal hiatus, which caused acute
pancreatitis. Axial CT scan 1 week later shows body—tail portion of
pancreas back in its anatomic position, in correlation with regression of
biologic abnormalities.
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Discussion
The hiatal hernia corresponds to the transient or permanent ascension of at
least part of the stomach into the thorax via the esophageal orifice of the
diaphragm. The migration of the stomach may be accompanied by various other
abdominal organs, including the colon, most often the splenic flexure, or
loops of the small intestine. The presence of small bowel in the hernial sac
is possible only if the transverse mesocolon is loose and similarly herniated,
as in our patient [6]. In such
a case, this stretching of the transverse mesocolon may allow the mobilization
of the pancreas after the lengthening of its posterior adhering fascia
[3,
7]. In our patient, the
mobilization of the pancreas was only partial: the duodenum and the head of
the gland were still in place, probably remaining tightly fixed in the back by
the fascia of Treitz. The herniation of the body—tail segment and its
rotation around the main axis led to a folding in the isthmus, which was
responsible for the obstruction of the main pancreatic duct shown by
endoscopic retrograde cholangiopancreatography.
Three descriptions exist in the literature of acute pancreatitis
complicating a diaphragmatic hernia. In the first two cases, the exact cause
of the acute pancreatitis was not known, and the authors proposed the
possibility of ischemia caused by the abnormal traction on the pancreas
[4,
5]. In the third case, the
acute pancreatitis was caused by the total incarceration of the gland in a
paraesophageal hernia without pancreatic volvulus
[3]. Henkinbrant et al.
[7] hypothesize that acute
pancreatitis occurring during the migration of the pancreas through a hernial
sac may be caused by repetitive trauma as it crosses the hernia, ischemia
associated with stretching at its vascular pedicle, or intermittent folding of
the main pancreatic duct. Our observation constitutes the first description
based on imagery of such a folding of the pancreatic duct.
In conclusion, patients with large hiatal hernias may present with
intermittent pancreatic volvulus. Although rare, this diagnosis should be
considered in patients with inexplicable pain associated with a large hiatal
hernia. CT should be performed, preferably during a symptomatic period.
Negative CT findings cannot exclude this diagnosis because of the possibility
that the pancreas may spontaneously revert to its normal anatomic
position.
Acknowledgments
We thank Frederic Oddo for preparing this manuscript.
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Introduction
Case Report
