The Potential Incidental: Clinical Correlation Required
Last time, Case 17 illustrated that being familiar with anomalous incidental findings can prevent false positive image interpretation. But it is also important while trying to answer your binary POCUS questions, to keep your eyes peeled for “incidental pathologies”. Such findings may or may not be the cause of the patients symptoms… so clinical correlation is required.
The Case
A 70 year old woman had been waiting in the radiology department for an x-ray to be taken. After standing for some time, she started to feel light headed, then collapsed. She was brought down to the urgent care clinic for assessment.
She made a rapid recovery, her observations were unremarkable and she denied chest pain, abdominal pain or palpitations. Her ECG did not show any concerning features.
A Focused TTE was performed. The descending thoracic aorta was not visualised, so the depth was increased. The following PSLA view was obtained. What do you think?
Disposition
A mass can be seen in the posterior mediastinum, immediately behind the the left atrium and anterior to the descending thoracic aorta.
The patient was referred to hospital to further investigate the cause of her collapse, in light of the uncertain aetiology of the echo findings. A CXR revealed a large hiatus hernia – the likely cause of the mass seen on TTE.
Discussion
- Hiatus hernia is an infrequent (<0.1%), but recognised extra cardiac finding on routine trans-thoracic echo (1).
- Features include an amorphous retrocardiac mass which may encroach on the posterior left atrial (or occasionally left ventricular) wall. The degree of impingement may vary with respiration. A swirling motion may be detected when the patient drinks an effervescent fluid (2).
- HH has been associated with post-prandial syncope, chest pain, and ECG changes suggestive of ischaemia. Hiatal hernia induced cardiac compression can also cause dyspnoea and cardiac failure (3,4).
- Being familiar with the echocardiographic appearance of HH may stop the POCUSer becoming flummoxed by such a finding. When investigating chest pain, dyspnoea or collapse, an hiatus hernia may be incidental, or causative of the patients symptoms. But as always, clinical correlation will be required!
More Examples
Ben Smith (@Ultrasoundjelly) and Jacob Avila (@UltrasoundMD) published a case of a patient presenting with chest pain and post-prandial dyspnoea at UOTW 39
And more recently from Twitter…
Abdominal pain Vomiting Tachycardia Tachypnea
— VCU Ultrasound (@ultrasound_vcu) December 29, 2018
Large hernia with outlet obstruction. Admitted for surgical repair.
Note left atrial compression; these can affect hemodynamics!https://t.co/ddsEt8RAK9
Also note thoracic aorta posterior to hernia#POCUS #FOAMed pic.twitter.com/v0B2zAWXxm
An elderly woman with chest discomfort
— Edgar Argulian (@argulian) October 31, 2018
#ACCFIT @JGrapsa @VLSorrellImages pic.twitter.com/LobfRATs01
References
1. Alkhouli M, Sandhu P, Wiegers SE, Patil P, Panidis J, Pursnani A. Extracardiac findings on routine echocardiographic examinations. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 2014; 27(5):540-6. [pubmed]
2. D’Cruz IA, Hancock HL. Echocardiographic characteristics of diaphragmatic hiatus hernia. The American journal of cardiology. 1995; 75(4):308-10. [pubmed]
3.Koskinas KC, Oikonomou K, Karapatsoudi E, Makridis P. Echocardiographic manifestation of hiatus hernia simulating a left atrial mass: case report. Cardiovascular ultrasound. 2008; 6:46. [pubmed]
4. Lim HS, Leong DP, Alasady M. Massive hiatus hernia mimicking a left atrial mass. Heart, lung & circulation. 2013; 22(10):875-6. [pubmed]
Header Image adapted from Radiopaedia.org
Case courtesy of Dr Jeremy Jones
urgentcareultrasound 