Strangulated Giant Paraesophageal Hernia Resulting in Ischemia and Perforation: A Case Report

An 82-year-old female presented with subacute onset of progressive epigastric pain, persistent retching, and respiratory distress due to a large strangulated paraesophageal hernia complicated by necrosis with perforation. While paraesophageal hernias are often long-standing and asymptomatic, they may evolve insidiously and present with life-threatening complications, e.g., strangulation. Computed tomography demonstrated marked intrathoracic herniation of the stomach filled with fluid, focal absence of mural enhancement, pneumatosis of the gastric wall, and scattered air densities within a high-attenuation pleural collection (27 HU). Imaging findings were highly suggestive of vascular compromise of the gastric wall with ischemia and perforation. Urgent surgery confirmed gastric wall discoloration consistent with ischemia and necrosis, along with hemorrhagic intrathoracic fluid. The patient was treated by a distal esophageal resection and partial gastrectomy, followed by reconstruction. This case highlights the importance of recognizing subacute presentation of complicated paraesophageal hernias, as delayed progression may lead to vascular compromise, necrosis, and ultimately perforation. The combination of absent gastric wall enhancement, intrathoracic free air, and high-density pleural fluid due to hemorrhagic content represents critical imaging features that should result in immediate surgical intervention.