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Looks like I made this one too easy – the correct answer is B) There is a hernia. A prominent hiatal hernia visible in this patient’s CT scan – this occurs when the stomach herniates into the chest through a normally restrictive break in the diaphragm that has widened.
Choice E is incorrect because the liver is not at all visualized in this sagittal section, and there is no mass present in the visible stomach (C); finally, very little lung is visualized on this section (D).
The patient’s symptoms of early satiety and epigastric pain are concerning given her history of malignancy >5 years prior to her presentation, together making the above answers more tempting.
Hiatal herniae do not typically cause problems for patients, and are not a concerning finding in an elderly patient – they are often found incidentally and no treatment is needed. They are more common in women, especially those who have been pregnant, those who are overweight, and those with chronic constipation – anything that increases intra-abdominal pressure can predispose one to develop a hiatal hernia.
When they are large enough to cause symptoms, patients may complain of belching, heartburn, discomfort or chest pressure, palpitations, or shortness of breath. Because of its protean presentation, the hiatal hernia has been referred to as the “great mimicker.” Severe cases with strangulation of the herniated portion of stomach may result in perforation (vomiting, fever, severe retrosternal pain, etc.), but again, is not how one would expect a hiatal hernia to present.