An uncommon etiology of nausea and vomiting: paraesophageal hernia

A 62 year old female on omeprazole with a history of hiatal hernia, gastroesophageal reflux disease (GERD), and esophagitis presented with acute onset of nausea and vomiting. She vomited approximately 20 times, quantified as half a cup mixed with dark red blood. Initially, the emesis was all recently ingested meals. The emesis became bloody after 24 hours of vomiting, leading to her presentation in the ER. She continued to feel nauseous with belching in the ER. She denied any abdominal pain, diarrhea, constipation, chest pain, odynophagia or shortness of breath. She had no melena, hematochezia, fevers, chills or weight loss. She denied any NSAID use or recent international travel. She had no family history of gastrointestinal malignancy and no history of tobacco use. Her physical examination and vital signs were unremarkable. Laboratory data was significant for white cell count of 18.78 K/µL, hemoglobin of 15.7 G/DL, hematocrit 46.3% (hemoglobin & hematocrit at baseline), mean corpuscular volume 88FL, platelet count 65 K/µL and INR was 1.0. Her chemistry, liver function test, lipase and amylase were within normal limits. Computed tomography(CT) scan of the chest was done.