A 79-year-old woman was referred to our department complaining of postprandial epigastric pain often radiating to the back, associated to early satiety, nausea and heartburn. She had a passed medical history of arterial hypertension and dyslipidemia. Aside from CHIR-99021 mild epigastric and left hipocondrial tenderness on abdominal examination, her physical examination was normal. Upper gastrointestinal endoscopy and

barium contrast study showed a bulky hiatal hernia (Fig. 1). No significative changes were seen on laboratorial or ultrasound investigation, although pancreas could not be properly visualized due to intense aerocolia. The research proceeded with an abdominal CT which enabled intrathoracic location of a great proportion of the stomach along with the body and part of the tail of the pancreas (Figure 2, Figure 3 and Figure 4). The patient was then submitted to surgical treatment. Reduction was easily effected, and the opening in the diaphragm was repaired. Recovery was uneventful and the patient became symptoms-free. Four types

of hernias have been described in the literature. Type I, also called sliding hernias, account for up to 95% of all hiatal hernias and occur when the GE junction migrates into the posterior mediastinum through the hiatus. Type II occurs when the fundus herniates alongside the esophagus through the hiatus, Sotrastaurin concentration remaining the GE junction normally positioned. Type III is a combination of types I and II hernias with a displaced GE junction as well as stomach protruding through the hiatus into the thorax Type IV paraesophageal hernias are very rare, representing 5–7% of all PEHH and result from a combination of increased intra-abdominal pressure and a large hiatal defect. The colon, particularly

the splenic flexure, is the most common organ that follows the stomach into the chest. Other common organs include loops of the small bowel and omentum. It is extraordinarily rare for the pancreas to herniate in paraesophageal hernias.2 Patients may be asymptomatic or present any of the typical or atypical symptoms seen Nutlin-3 datasheet in the other three hernia types.3 Symptomatic PEHH in operable patients should be repaired. The underlying surgical principles for successful repair include reduction of hernia contents, removal of the hernia sac, closure of the hiatal defect, and an antireflux procedure.4 The authors declare that no experiments were performed on humans or animals for this investigation. The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study. The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document. The authors have no conflicts of interest to declare.