Giant Type IV hiatal hernia with intrathoracic migration of abdominal viscera and atypical clinical presentation: a case report.

The Type IV paraesophageal hernia is the rarest and most treacherous hiatal hernia: herniated viscera compressing the chest cavity can imitate cardiopulmonary symptoms convincingly enough to derail the diagnostic workup. We describe a 57-year-old man in whom a Type IV hiatal hernia, which found incidentally 25 years earlier, had enlarged into a giant 15 × 12 cm defect with a 180-degree organoaxial gastric volvulus. He presented not with reflux but with orthopnoea, nocturnal cough, postprandial palpitations, and muffled heart sounds; only after a normal cardiac workup did computed tomography reveal stomach, colon, and small bowel within the thorax. Laparoscopic reduction, sac excision, cruroplasty, Nissen fundoplication, and mesh hiatoplasty resolved every symptom, with an intact repair confirmed at three years. This case captures the natural history of a neglected hernia and argues for early cross-sectional imaging when cardiopulmonary symptoms outlast a normal cardiac and pulmonary evaluation.