Giant hiatal hernia: beware of the supine ICU chest X-ray!

Description

An 85-year old woman with a medical history of mild hiatal hernia was admitted to the medical intensive care unit for respiratory distress associated with hypoxaemia and hypercapnia. A diagnosis of cardiogenic oedema was suspected. The situation slightly improved after high-dose diuretics and non-invasive ventilation. The anteroposterior supine chest X-ray revealed a right thoracic opacity. The patient was transferred to the pulmonology unit. A classical erected posteroanterior chest X-ray revealed a large air-fluid level in the right hemithorax (figure 1). An hydropneumothorax or a lung abscess was suspected. A chest CT scan revealed a giant hiatal hernia containing the stomach, the first duodenum, the spleen, the caudal part of the pancreas and the left colic flexure, all elevated in the right hemithorax (figure 2A–C; ). A laparoscopic surgical procedure was performed which involved the excision of the hernia sac, a suture repair of...

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