Combined hiatal and pleuroperitoneal hernia

in a shar-pei
Jerome M. Auger, Steve M. Riley

Abstract This article presents an unusual combination of a type IV hiatal hernia and a pleu-
roperitoneal hernia in a young shar-pei. Pathogenesis, diagnosis, and treatment of both conditions
are discussed. At surgery, close examination and palpation of the whole diaphragm are recommended
to allow perioperative diagnosis of unexpected defects.

Resume Hernie hiatale et pleuroperitoneale combinee chez un Shar-pei. L'article traite de

la combinaison inhabituelle d'une hernie hiatale de type IV et d'une hernie pleuroperitoneale
chez un jeune Shar-pef. Il est question de la pathogenese, du diagnostic et du traitement des deux con-
ditions. Lors d'une chirurgie, il est recommande de proceder a un examen attentif et a la palpation
du diaphragme pour permettre le diagnostic de defauts imprevus.
(Traduit par Helene Petitclerc)
Can Vet J 1997; 38: 640-642

A 13.5 kg, 9-month-old, castrated male shar-pei was

presented to the Ontario Veterinary College,
Veterinary Teaching Hospital (OVC, VTH) because of
chronic vomiting and regurgitation, hypersalivation,
and poor body condition. Signs had started approxi-
mately 6 mo prior to presentation, shortly after weaning.
The vomit consisted of food or, more often, white or,
occasionally, yellow-tinged frothy material. The dog had
been tried on various diets and it appeared that canned
food elicited less postprandial vomiting than did dry food.
An endoscopy, performed 6 mo prior to referral by the
referring veterinarian, revealed hyperemic esophageal and
gastric mucosae. Treatment for gastritis and reflux
esophagitis with cimetidine, sucralfate, and metoclo-
pramide had been given, at recommended doses, for
several months prior to referral, without significant Figure 1. Left lateral thoracic radiograph. Megaesophagus
improvement. and an air-filled oval structure protruding into the thorax are
On examination, the dog appeared abnormally thin and clearly visible.
was drooling profusely. The dorsal aspect of the front
paws was brown-stained, attributable to persistent soil- esophageal motility and gastroesophageal reflux. The gas-
ing by saliva. Auscultation of the thorax discerned shal- troesophageal junction was located several centime-
low breathing and decreased lung sounds over the left ters cranial to the diaphragm, and the gastric fundus pro-
caudo dorsal thorax. Results from a complete blood truded into the left thorax to the level of the 7th rib. These
cell count, a biochemistry profile, and a urinalysis were findings were characteristic of a combined axial and
within normal limits. Chest radiographs showed a paraesophageal hiatal hernia (1,2). Medical and surgical
megaesophagus and revealed an oval, thick-walled options were discussed with the owners, who opted for
structure, compatible with the stomach, cranial to the surgical correction, since an appropriate medical treat-
diaphragm in the area of the esophageal hiatus (Figure 1). ment had previously failed to bring about significant
On the basis of the breed, clinical signs, and radi- improvement.
ographic findings, we made a tentative diagnosis of The next day, the dog was anesthetized and the skin of
hiatal hernia. the ventral abdominal wall was prepared for a sterile pro-
A barium esophagram confirmed the megaesophagus cedure. A cranial midline celiotomy was performed.
and herniation of a large part of the stomach into the tho- The cranial part of the abdominal cavity and esophageal
rax. Fluoroscopy of the barium swallow revealed good hiatus were examined. Reduction of the hernia by gen-
tle traction on the stomach revealed that the left lateral
lobe of the liver and the spleen were displaced into the
Department of Clinical Studies, Ontario Veterinary College, thoracic cavity along with the cardiac and fundic portions
University of Guelph, Guelph, Ontario NIG 2W1. of the stomach. These organs were easily pulled from
Present address for Dr. J.M. Auger: Department of Clinical the thorax and repositioned in the abdominal cavity.
Sciences, Faculty of Veterinary Medicine, University of A membranous hernial sac was present and there was no
Montreal, C.P. 5000, Saint-Hyacinthe, Quebec J2S 7C6. communication between the abdominal and thoracic
640
A4Cn Vlme3,Ocoer19
Can Vet J Volume 38, October 1997
 cavities. The loose hiatus was reduced to an opening the Chinese shar-pei, since this breed is over-represented
2 cm in diameter, using simple interrupted sutures of in the literature reports. An investigation of the mode of
2/0 polypropylene to imbricate the crura of the diaphragm inheritance has not been attempted at this time, proba-
ventral to the esophageal hiatus (2,3). The index finger bly because most cases are isolated. Four main types of
was used for palpation of the esophagocardiac junc- hiatal hernia are described in the human medical literature
tion to evaluate the degree of reduction in diameter (1) and have been transposed to the veterinary field. The
thus achieved. A fundic belt-loop gastropexy was per- type I hiatal hernia is a sliding or axial hernia and
formed to anchor the stomach to the left abdominal seems to be, by far, the most common type diagnosed in
wall and avoid reherniation. Thoracocentesis was per- the dog (3,4,7-9,12). It corresponds to a cranial dis-
formed transdiaphragmatically to restore intrathoracic placement of the gastroesophageal junction into the
negative pressure. Closure of the celiotomy was routine. thoracic cavity. The type II, rolling or paraesophageal,
The immediate postoperative period was unevent- hiatal hernia corresponds to a herniation of the stomach
ful; however, 24 h after surgery, the dog was still sali- through an enlarged hiatus while the gastroesophageal
vating abundantly and vomiting more frequently than junction remains in a nearly normal position. Although
expected. Thoracic and abdominal radiographs were they are frequently referred to synonymously, the true
taken and appeared surprisingly similar to those taken paraesophageal hiatal hernia differs from the type II
preoperatively; it was debated whether the surgical hernia in that it occurs through a separate diaphrag-
repair had ruptured and hemiation had reoccurred. After matic defect adjacent to the esophageal hiatus. The
further discussion with the owners, a 2nd surgery was type III hiatal hernia is a combination of types I and II.
scheduled. The previous incision was opened and the The type IV hernia is a type III hernia complicated by
belt-loop gastropexy, which was found intact, was herniation of abdominal organs, in addition to the stom-
released to allow manipulation of the stomach and ach, into the thoracic cavity. It, therefore, applies to the
deeper exploration of the abdominal cavity. The latter case described here.
revealed that the pyloric portion of the stomach and Congenital pleuroperitoneal hernia is rare in small
the pylorus had herniated into the thoracic cavity, not animals (3). One case has recently been reported in a
through the esophageal hiatus but through the dorsal or cat (1 1). Embryological formation and malformation of
lumbar part of the diaphragm (5), which consisted of a the diaphragm have been well described by Noden and
flaccid membrane instead of the muscular layer. During de Lahunta (6). Pleuroperitoneal hernia results from
the 1 st surgery, palpation of this area had not detected incomplete closure of the peritoneal canals (dorsal part
obvious abnormalities, and visual examination was not of the diaphragm) or from failure of the pleuroperi-
performed. The location of this diaphragmatic defect cor- toneal folds to incorporate muscular components of
responded to that of the pleuroperitoneal folds during the body wall. In the former situation, an opening per-
embryogenesis, and this defines the resulting pleu- sists between the thoracic and abdominal cavities, which
roperitoneal hernia (6). A stomach tube was inserted leads to rapid death by respiratory insufficiency (3).
orally to keep the cardia open for the next surgical In the latter, the lumbar part of the diaphragm remains
step. The flaccid portion of the diaphragm was plicated membranous instead of becoming a strong muscular
using 2/0 polypropylene mattress sutures, dorsal to the layer. Thus, it acts like a hernial sac, as in the case we are
esophageal hiatus. Thoracocentesis was performed reporting. This was not recognized by palpation at the
transdiaphragmatically to restore intrathoracic nega- 1st surgery. It is possible that the corresponding weak-
tive pressure. A 12 cm longitudinal incision was made ened area became significant only after reduction of
in the seromuscular layer of the ventral gastric wall, mid- the abdominal organs and correction of the hiatal hernia.
way between the attachments of the lesser and greater The history and clinical signs of this dog were highly
omenta and ending over the pyloric canal. It was then suggestive of an esophageal hiatal hernia. Clinical signs
included in the closure of the linea alba using 0 poly- commonly appear shortly after weaning, at the time of
dioxanone and 2/0 polypropylene simple interrupted transition from liquid to solid food. Hypersalivation
sutures to create a permanent midline gastropexy. The and vomiting or regurgitation, especially in the imme-
rest of the closure was routine. diate postprandial period, are reported by most authors
The dog recovered well from the 2nd surgery and (3,4,7-9). Often, poor body condition results from this
immediate abatement of the clinical signs was observed. altered digestive function. Dyspnea and exercise intol-
Prior to discharge, instructions were given to the own- erance have also been observed and seem secondary to
ers to feed their animal from an upright position and to either aspiration pneumonia or lung compression by
watch for signs of aspiration pneumonia. Sucralfate the herniated abdominal organs. The risk of fatal com-
was prescribed at 0.5 g, PO, q8h for 3 wk for possible plications, such as, gastric volvulus, torsion, obstruction,
esophagitis. At recheck 2 wk postoperatively, hyper- strangulation, and intrathoracic dilatation, is dreaded in
salivation was no longer present and only occasional humans with a type II hiatal hernia and prompts surgi-
vomiting was reported by the owners. Chest films did not cal correction, even in asymptomatic cases (1). Callan
reveal any abnormalities. Six months after the procedure, et al (8) reported 2 fatal cases with "acute large gastric
the owners were contacted and they reported that the dog herniation" in the shar-pei. In our patient, both the
was asymptomatic. esophageal hiatal and pleuroperitoneal hernias probably
Esophageal hiatal hernia has been reported previ- contributed to the clinical signs; however, it is difficult
ously in the dog (2,4,7-12). It is usually a congenital con- to determine their respective importance.
dition; however, acquired hiatal hernia has been described An isolated pleuroperitoneal hernia can be diag-
(4,7,12). A predilection to this disorder is suspected in nosed by paracostal ultrasonography and, possibly,
Can Vot
V*t J Volume 38, October 1997 641
 by positive-contrast peritoneography to outline the motility seem to resolve postoperatively, in most cases.
diaphragmatic defect (11). Diagnosis of esophageal Likewise, the megaesophagus was no longer present
hiatal hernia is based on history, clinical signs, and at the 2-week re-evaluation of our patient. The megae-
survey radiographs of the thorax, which may reveal sophagus observed probably resulted from cranial dis-
the presence of a gas-filled, soft tissue structure cranial placement of the cardia, and it could be more appropriate
to the diaphragm, megaesophagus, and masses with a soft to refer to it as esophageal dilatation. The medical treat-
tissue density when the spleen or liver have herniated ment described above may be given for 1 to 3 wk after
(2,3). Contrast studies with oral administration of bar- surgery.
ium are necessary to outline the hernia precisely and Congenital pleuroperitoneal hernia is a rare occurrence
to diagnose more subtle sliding or type I hernias. in the dog. To our knowledge, the combination of this
Fluoroscopic examination following barium adminis- hernia and a type IV hiatal hernia has not been described
tration should be performed to assess esophageal motil- in the veterinary literature. Multiple degrees of con-
ity and the degree of gastroesophageal reflux. It is par- genital diaphragmatic hernia may be found in the dog;
ticularly important when dealing with the shar-pei, in however, congenital absence of portions of the lum-
which various degrees of esophageal dysfunction have bar part of the diaphragm can rapidly be fatal after
been demonstrated (13). In this breed, an apparently iso- birth. The defect seen in this dog was probably as
lated megaesophagus should raise suspicion of an asso- severe as it can be in a near-adult animal.
ciated esophageal hiatal hernia. Ultrasonography would During surgical treatment of a hiatal hernia, the entire
probably enable identification of the herniated organs. diaphragmatic surface should be closely inspected after
This was not done in our case. the herniorraphy has been completed, to allow identi-
Medical treatment can be attempted in animals with a fication and subsequent closure of any concurrent defect.
small sliding hernia. It consists of feeding modifications Finally, the increasing likelihood of a breed predis-
(upright feeding and change in the consistency of the position for hiatal hernia in the shar-pei should motivate
diet) and the use of antacids, like H2 agonists (cimetidine, future genealogical and genetical studies of affected
ranitidine) and prokinetic agents (metoclopramide). animals. cvj
Bright et al (7) recommended that medical treatment be
administered for 1 mo before contemplating surgical References
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642 Can Vet J Volume 38, October 1997