Medical Excellence - Issue 2

A Rare Cause of Excruciating Chest Pain Mimicking Acute Coronary Syndrome L. Hobohm 1 , D.Krompiec 1 , R. Michel 1 , Y. Yang 2 , F. Schmidt 1 , C. Düber 2 , T. Münzel 1 , P. Wenzel 1 A 62-year-old male presented to the chest pain unit with chest pain and nausea, reporting that the symptoms occurred one hour after dinner. His medical history included a foudroyant event of pulmonary embolism with embolectomy in 2012. Due to clinical deterioration and the history of pulmonary embolism, we decided to perform a contrast computed tomog- raphy angiography (CT). We could rule out aortic dissection and pulmonary embolism, However, CT revealed a mixed axial para- oesophageal upside-down stomach (UDS) compressing the left ventricle (Fig. 1). Upside-down stomach is the rarest type of hiatal hernia and can manifest clinically in a wide variety of symptoms as demon- strated in this case [1]. As causes of chest pain, gastrointestinal disease other than peptic ulcer or reflux-related diseases which might include UDS were reported to be below 1% [2]. In UDS patients, complications such as incarceration, volvulus develop- ment as well as acute gastric bleeding can lead to a life-threat- ening emergency with prevalence of 30.4% and can require im- mediate surgery [3, 4]. Conflict of interest  L. Hobohm, D. Krompiec, R. Michel, Y. Yang, F. Schmidt, C. Düber, T. Münzel and P. Wenzel declare that they have no com- peting interest. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons. org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. References 1. Hill LD, Tobias JA. Paraesophageal hernia. Arch Surg. 1968;96:735–44. 2. Verdon F, Herzig L, Burnand B, et al. Chest pain in daily practice: oc- currence, causes and management. Swiss MedWkly. 2008;138:340–7. 3. Hill LD. Incarcerated paraesophageal hernia. A surgical emergency. Am J Surg. 1973;126:286–91. 4. Trainor D, Duffy M, Kennedy A, Glover P, Mullan B. Gastric perfora- tion secondary to incarcerated hiatus hernia: an important differ- ential in the diagnosis of central crushing chest pain. EmergMed J. 2007;24:603–4. Source: Hobohm, L., Krompiec, D., Michel, R. et al. Neth Heart J (2017) 25: 58. https://doi.org/10.1007/s12471-016-0913-8. © The Author(s) 2016. L. Hobohm (  ) lukas.hobohm@unimedizin-mainz.de 1 Center of Cardiology, Cardiology I, Johannes Gutenberg University Medical Center Mainz, Mainz, Germany 2 Department of Diagnostic and Interventional Radiology, Johannes Gutenberg University Medical Center Mainz, Mainz, Germany Fig. 1: Computed tomography ( a ) and gastrointestinal contrast series ( b ) show a mixed axial and para-oesophageal upside-down stomach ( red arrow ) compressing the left ventricle, without any incarcerated portions of the stomach. Issue-2  |  5 MEDICAL EXCELLENCE