Rare case of upside-down stomach in advanced hiatal hernia
Upside-down stomach (UDS) is the rarest type of hiatal hernia, which is migration and volvulus of the entire stomach into the posterior mediastinum. We present a case of a patient with chronic gastroesophageal reflux disease (GERD) and myelodysplastic syndrome diagnosed 3 months ago, admitted for syncope and signs of aspiration pneumonia, with incidental findings of hiatal hernia type IV with UDS. A 74-year-old Caucasian male presented to the emergency department complaining of syncope. The patient had been experiencing generalized weakness and a history of multiple falls without head injury. Upon physical examination the patient was not in acute distress. The chest x-ray was suspicious for pneumonia. Upon admission, the patient had a hemoglobin level of 6.8 g/dl. He was transfused with multiple units of packed RBCs during his stay for treatment of his anemia secondary to myelodysplastic syndrome. A CT thorax revealed a large hiatal hernia type IV with UDS within the posterior mediastinum. Surgical intervention was recommended, but the patient elected to postpone surgery due to no symptoms and was discharged. The patient died one month later from complications related to myelodysplastic syndrome. The diagnosis of upside down stomach can be suspected on chest X-ray but requires a high degree of suspicion. All surgical interventions for UDS must consider the overall prognosis of the patient and estimated improved quality of life before repair, especially with the high recurrence of UDS even after surgical repair.