Hiatal Hernia: The Great Masquerade in the Emergency Department

Chest pain and dyspnoea are among the most common complaints seen in the emergency room and each symptom calls for a broad differential diagnosis. Large hiatal hernias are infrequent, but they can lead to atypical symptoms mimicking different cardiovascular, pulmonary and neoplastic diseases. We present two cases of older patients with an apparent left atrial mass on transthoracic echocardiography, which was subsequently identified as hiatal hernia by other imaging modalities. A multidisciplinary team with multimodality imaging is necessary for diagnostic work-up of chest pain and dyspnoea of non-cardiac origin and especially for a suspected mass compressing the heart, causing chest discomfort. LEARNING POINTS: Hiatal hernia (HH) can mimic different cardiovascular, pulmonary and neoplastic diseases. HH has a typical echocardiographic (2DE) presentation as an amorphous, echolucent mass with the appearance of a left atrial space-occupying lesion. Oral ingestion of a carbonated drink may help to distinguish between a large HH and an atrial mass by 2DE.