Perforated peptic duodenal ulcer in a paraesophageal hernia – a case report of a rare surgical emergency

An elderly man with multiple medical conditions was admitted due to severe upper abdominal pain. The patient was found to have a paraesophageal hernia and underwent a laparotomy. In the hernia, a perforated benign peptic duodenal ulcer was found. The duodenal defect was over-sewn, the hernial defect was closed and the former hernial cavity was drained by a right-sided chest tube. The patient was discharged one month after surgery and was found to do well at follow-up one month after discharge.This is the first report of a patient surviving the extremely rare and life-threatening combination of a perforated peptic duodenal ulcer in a paraesophageal hernia.The distinction between a sliding hiatal hernia and a paraesophageal hernia is based on whether the esophagogastric junction (cardia) is above (sliding hernia or type I hiatal hernia) or below (paraesophageal hernia) the diaphragm. Paraesophageal hernias are true hernias with a covering peritoneal sac. Alternative names found are type II hiatal hernia, rolling hiatal hernia, intrathoracic stomach and up-side down stomach. A paraesophageal hernia with a sliding component is often termed a type III hernia.Since paraesophageal hernias present in adult life in the majority of cases, acquired causes such as mechanical forces and tissue degeneration are probable etiological factors, albeit congenital factors cannot be ruled out since paraesophageal hernias and its complications also exist in the pediatric literature [1-5]. The incidence of paraesophageal hernias in per cent of all hiatal hernias ranges between 0, 5–19 % depending on whether or not to include mixed hernias, author's definition of paraesophageal hernia, and whether to include allcomers or only surgically treated patients [6].The clinical presentation of paraesophageal hernias may be of wide range, from an incidental finding at one hand, to a catastrophic and life threatening condition at the other. If strangulation is suspected, decompression by a naso-gast