Recurrent supraventricular extrasystolia due to retrocardiac stomach

TO THE EDITOR: Gastric hiatal hernia is a relatively common condition in general population. It is often asymptomatic. In symptomatic patients it is generally associated with gastroesophageal reflux disease (GERD) with symptoms of heartburn, dysphagia, or syalorrhea. However, in some cases it may be giant and provoke severe complications. In February 1999 a 75-yr-old woman was admitted for our observation because of weakness, desultory dysphagia, and heartburn for about 2 months. She also experienced recurrent episodes of palpitation from orthostatic to clinostatic position. The only objective report on physical examination were unusual borborigms on mitral focus. An electrocardiogram in clinostatism showed the presence of a high degree of sopraventricular extrasystolia, which was absent in orthostatism. The esophagogastroduodenoscopy showed the presence of a severe hyperemia of the distal esophagus, a large hiatal hernia with two ulcers (diameters about 0.8 and 1 cm, respectively) (Fig. 1) and hyperemia of the antrum. We performed an x-ray barium examination, which showed the presence of a giant gastric hernia with thoracic dislocation of fundus and body compressing the left atrium, but not perforation into the heart (Fig. 2 A and B). The patient was given intravenous omeprazole and treated surgically by Nissen-Rossetti fundoplication 1 wk later. The symptoms of GERD improved dramatically and the extrasystolia disappeared immediately after the surgery. On the last examination (April 2000) the patient was symptom-free, without any subjective or objective sign of sopraventricular extrasystolia. Giant gastric hernia can sometimes mimick a left atrial mass, but it is generally asymptomatic and the diagnosis is often casual (1, 2). On the contrary, in our case the com-