Transverse colon incarceration and necrosis in a hiatal hernia: a case report.

Introduction and importance: Incarcerated necrosis of the transverse colon is a rare but severe complication of hiatal hernia. While Type I hiatal hernias are common, Type IV hernias involving other abdominal organs are infrequent. This case aims to alert clinicians to this condition's atypical manifestations to ensure timely surgical intervention. Case presentation: An 80-year-old female was admitted with a 2-day history of vomiting, abdominal distension, and acid reflux. Following admission, she developed hematochezia. An emergency contrast-enhanced CT scan revealed a Type IV hiatal hernia with the transverse colon herniated into the posterior mediastinum, accompanied by ischemic changes. Emergency laparoscopic exploration confirmed necrosis of the incarcerated transverse colon. The patient underwent reduction of the hernia, resection of the necrotic bowel, transverse colostomy, and hiatal hernia repair. The operative time was 210 minutes, with an estimated blood loss of 100 mL. The patient recovered well and was discharged on day 11. Clinical discussion: Diagnosis of hiatal hernia typically relies on imaging; however, the presence of hematochezia in this context is a distinct red flag for intestinal ischemia or necrosis. Unlike asymptomatic cases, this presentation necessitated emergency surgery. The laparoscopic approach allowed for effective management of both the hernia and the bowel resection while minimizing surgical trauma. Conclusion: Clinicians must be vigilant regarding the potential complications of hiatal hernias, particularly in elderly patients presenting with gastrointestinal bleeding. Early use of CT imaging and prompt surgical intervention are essential to minimize postoperative complications and promote recovery.