Life-Threatening Cardiac Compression Secondary to a Massive Hiatus Hernia With Gastric Volvulus: A Case Report

Large hiatal hernias are typically managed conservatively; however, in rare instances, they can lead to life-threatening mechanical cardiovascular complications through direct extrinsic compression of the cardiac chambers rather than pericardial fluid accumulation, producing "functional" tamponade physiology. An 88-year-old man presented to the emergency department with sudden worsening of a three-day history of chest and upper abdominal pain radiating to the back. On arrival, he was vomiting, dyspneic, pale, and hypotensive (blood pressure: 96/52 mmHg). A CT angiogram revealed a massive hiatal hernia containing the stomach and transverse colon, complicated by gastric volvulus and anterior cardiac compression consistent with tamponade physiology. Nasogastric decompression was unsuccessful due to distorted anatomy. The patient subsequently underwent an urgent esophagogastroduodenoscopy (OGD) within one hour of CT acquisition, which aspirated 1.1 L of thick gastric contents, leading to the resolution of the cardiac compression. OGD was chosen over immediate surgical intervention due to the patient's frailty and comorbidities, with the aim of rapid decompression and minimizing the perioperative risk. He made a full recovery and was discharged shortly thereafter, remaining symptom-free at the three-month follow-up. This case highlights a rare but critical complication of massive hiatal hernia causing functional cardiac tamponade. Prompt recognition through CT imaging and timely endoscopic decompression can be life-saving.