A 45 y.o. male comes in with abdominal pain; he volunteers that he was told " his stomach is stuck to his liver"
What do you notice on his CT?
there is something in the epigastric area as well; see the image below
What would cause the esophagus shown in yellow to be going through the stomach outlined in red?
Our patient had a Nissen fundoplication and it had herniated into his chest. In this operation the stomach is wrapped around the distal esophagus to prevent reflux. In our particular patient this has herniated into the chest.
The Nissen fundoplication
The Nissen fundoplication
Rudolph Nissen performed the first fundoplication in 1955. By wrapping the stomach around the lower esophagus, the lower esophageal sphincter is reinforced. When the stomach contracts, gastric acid is not forces back into the esophagus because the stomach contracts around the esophagus. The operation is reported to be effective with 89.5% of patients symptom free after 10 years.
There are two conditions where there can be symptoms when the wrapped esophagus herniates into the chest. The first is when the closure of the diaphragm partially breaks down creating a small defect where the hernia becames pinched as it moves into the chest. The second is where there is a partial breakdown of the 360 degree wrap around the stomach and part of the stomach slides up into the chest and the remaining wrap slides down along the stomach like a slip knot. This can cause a smaller upper stomach which leads to a feeling of fullness or in extreme cases can cause ischemia of the stomach.
In both these cases the wrap herniated causing obstruction which can lead to ischemia
In these cases there is no obstruction and the herniated wrap is asymptomatic
Our patient was actually asymptomatic from his herniated Nissen wrap and had a 7 mm L kidney stone with mild hydronephrosis demonstrated on the CT. He had pain intermittently for a month. Urology took the pt to the OR for stone extraction which resulted in resolution of his abdominal symptoms. . Adhesions to the liver can occur after a Nissen so the patient may have been accurate in his original complaint.
Deswysen Y, Volonte F, Gutschow C, et al. European Journal of Cardio-Thoracic Surgery. 2014 Volume 46(1):121-126, https://doi.org/10.1093/ejcts/ezt553
Minjarez R, Jobe B. surgical therapy for gastroesophageal reflux disease. 2006 Mobility Online. 2006 doi:10.1038/gimo56
Nissen R. Gastropexy and fundoplication in surgical treatment of hiatal hernia. 1961 The American Journal of Digestive Diseases. 6(10):954-61. Doi10.1007/BF022231426.