A Giant Hiatal Hernia (GHH) is a type III hernia with a sliding and para esophageal component such as > 30% of the stomach, colon, spleen or pancreas due a chronic positive pressure on the diaphragmatic hiatus. Surgical repair requires hernia sac excision, tension-free repair and Nissen fundoplication. Recurrence rates range between 2% and 12%. A 77 years old Caucasian woman presented to the ED with significant thoracic pain, vomiting and bradycardia (<50 bpm). She presented a medical history of atrial fibrillation and anticoagulant therapy. She reported a traumatic rupture of the sternum 5 years ago. Her vital signs were: blood pressure, 130/70 mm Hg; respiratory rate, 40 breaths/minute; heart rate, 129 beats/minute; and temperature superior of 36°C. Oxygen saturation was 85% on room air. The abdominal examination was normal. Thoracic examination reported reduced vesicular murmur. Laboratory evaluation revealed high leukocytosis with a white blood cell (WBC) count of 16 per mm³. Arterial Blood Gases (ABG) demonstrated metabolic acidosis. Computed Tomography revealed a Giant Hiatal Hernia with stomach, ileum and colon in thoracic cavity. The patient was immediately started intravenous (IV) fluids of 2l in 6 hours, Foley and jugular catheter vein cannulation to support main arterial pressure and urine output. The patient was discussed for surgical operations.

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Corresponding author
Danilo Coco, Department of General Surgery, Ospedali Riuniti Marche Nord, Pesaro, Italy (webcostruction@msn.com)