ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI

A Man With Two Gastric Bulbs

Hsueh-Chien Chiang, Jui-Wen Kang, and Xi-Zhang Lin

Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung
University, Tainan, Taiwan

Question: An 82-year-old man presented to the emer-

gency department with a 3-day history of dull epigas-
tralgia. The physical examination was notable for
distended abdomen and epigastric tenderness. Laboratory
examination revealed elevated white blood cell count
(14,200/mL), elevated serum lactate (3.1 mmol/L). A
chest radiograph (Figure A) showed 1 sac with an
air–fluid level around the right diaphragm symmetry to
the gastric bulb below the left diaphragm.
What is the diagnosis and how should it be managed?
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Correspondence
Address correspondence to: Hsueh-Chien Chiang, MD, Department of
Internal Medicine, National Cheng Kung University Hospital, College of
Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan
704, Taiwan. e-mail: scion456scion@gmail.com; or Xi-Zhang Lin, MD,
e-mail: linxz@ncku.edu.tw.

Acknowledgment
Hsueh-Chien Chiang and Xi-Zhang Lin contributed equally.
Conflicts of interest
The authors disclose no conflicts.

© 2021 by the AGA Institute

0016-5085/$36.00
https://doi.org/10.1053/j.gastro.2021.02.038

Gastroenterology 2021;161:e12–e13
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
Answer to: Image 5: Paraesophageal Hiatal Hernia

A computed tomography scan of the chest (Figure B, C) showed hiatal herniation with involvement of gastric antrum and
transverse colon. Epigastralgia may be related to transverse colon and gastric antrum trapped in the hernia sac. We inserted
a nasogastric tube for gastric decompression. After esophagogastroduodenoscopy ruled out gastric malignancy, a laparo-
scopic hiatal hernia repair was performed. During the surgery, the space of hiatal hernia in the thoracic cavity was checked,
and the hernia sac was separated from pleura. The hernia sac was removed. Abdominal pain was relieved after surgery.
Keywords: Paraesophageal Hiatal Hernia; Air-fluid Level; Epigastralgia.

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