hiatal hernias represent a frequent gastrointestinal disorder caused by herniation of abdominal organs through the esophageal hiatus . the etiology of hiatal hernias is based on three mechanisms : widening of the diaphragmatic hiatus , pulling up of the stomach by esophageal shortening and pushing up of the stomach by increased intraabdominal pressure . accordingly , there is a high prevalence of hiatal hernias in power athletes and obese people [ 2 , 3 ] . moreover , familial clusters of hiatal hernias have been described , and the prevalence of hiatal hernias is increased in western populations as shown by a comparison of english ( 49% ) and singaporean ( 4% ) patients with dyspepsia who underwent upper endoscopy [ 4 , 5 ] . it is characterized by a partial herniation of the stomach associated with insufficient closure of the esophageal orifice due to a widening of the muscular hiatal tunnel . type ii , iii and iv hiatal hernias are variants of a paraesophageal hernia . in opposition to type i hernia , the gastroesophageal junction of type ii hernia remains fixed to the preaortic fascia and the median arcuate ligament . however , a defect in the phrenoesophageal membrane allows gastric herniation , and a continuous enlargement of type ii hernia leads to intrathoracic placement of the stomach with the pylorus juxtaposed to the gastric cardia , also referred to as upside - down stomach . type iii hernia consists of type i and ii elements , and type iv hernia is caused by a large defect in the phrenoesophageal membrane which allows herniation of other abdominal organs such as colon , spleen , pancreas and small intestine . the most common symptom is heartburn caused by gastroesophageal reflux disease , which can be successfully treated with proton pump inhibitors . by contrast , patients with paraesophageal hernias are at risk of complications such as incarceration , bleeding , strangulation or perforation . a 60-year - old male patient was admitted to our hospital with epileptic seizures and dehydration . laboratory tests showed an elevated serum ph ( 7.56 ) , increased levels of bicarbonate ( 67.5 mmol / l ) and unmeasurable base excess representing a metabolic alkalosis which was partially compensated by increased carbon dioxide ( 76 mm hg ) ( table 1 ) . mmol / l ) were reduced whereas sodium was normal ( 143 mmol / l ) . moreover , elevated levels of hematocrit ( 53% ) and creatinine ( 651 mol / l ) confirmed massive dehydration ( table 1 ) . to rule out differential diagnosis , serum concentrations of adrenocorticotropic hormone ( acth ) , cortisol , renin and aldosterone were determined . while levels of cortisol ( 84.3 g / dl ) , renin ( 83.6 pg / ml ) and aldosterone ( 289 pg / ml ) were elevated , acth ( 32.5 pg / ml ) as well as the aldosterone / renin ratio ( 3.46 ) were not altered ( table 2 ) . this constellation points to an activation of the sympathetic nervous system but does not support endocrinological disorders such as cushing or conn syndrome . abdominal ultrasound excluded postrenal failure , and an enlarged stomach indicated gastric outlet obstruction ( fig . thereupon we observed a large hiatal hernia with an intrathoracic pylorus and multiple mucosal hemorrhages ( fig . this result was confirmed by computed tomography , which showed an upside - down stomach in the posterior mediastinum and a hiatal hernia 3.5 cm in diameter ( fig . 3 ) . moreover the stomach was surrounded by a fluid fringe indicating incipient incarceration . as an additional finding , pulmonary infiltrates in the right inferior lobe indicated aspiration pneumonia . taken together , we diagnosed severe hypochloremic metabolic alkalosis and acute prerenal failure which were caused by recurrent vomiting due to an upside - down stomach and triggered epileptic seizures . intravenous application of sodium chloride 0.9% and potassium improved acid - base state , electrolyte homeostasis and kidney function . subsequently , the patient was referred to the department of surgery and hiatoplasty with fundoplication was successfully performed . about one third of patients with a type ii hernia develop complications such as intrathoracic incarceration , bleeding , strangulation or perforation . accordingly , the most common symptoms include thoracoabdominal pain , heartburn , dysphagia , vomiting and signs of gastrointestinal bleeding , but also dyspnea , cough or precordial oppression can result from intrathoracic squeezing effects of paraesophageal herniation . in addition to such common symptoms , the patient described above developed severe systemic disorders including metabolic alkalosis , acute renal failure and epileptic seizures . recurrent vomiting due to an upside - down stomach resulted in the loss of large amounts of gastric acid which caused metabolic alkalosis and acute prerenal failure . as a differential diagnosis the milk - alkali syndrome , gastric hypersecretion or a large excess of adrenocortical hormones need to be considered . the milk - alkali syndrome is caused by a high intake of calcium carbonate triggering hypercalcemia , metabolic alkalosis and acute renal failure . the latter two effects can also occur in patients suffering from short bowel syndrome with gastric hypersecretion . however , the clinical course of disease , the absence of hypertension , hyperglycemia or calcium dysregulation as well as normal levels of acth and aldosterone / renin ratio excluded these differential diagnoses . taken together , this case report highlights upside - down stomach as a possible cause of severe systemic disorders including metabolic alkalosis , acute renal failure and epileptic seizures . furthermore , the course of disease confirms that surgical treatment of symptomatic type ii hiatal hernias should be performed to prevent life - threatening complications .
upside - down stomach represents a critical and rare manifestation of hiatal hernias . here 
 we report on a 60-year - old male patient who was admitted to our hospital with epileptic seizures and dehydration . 
 laboratory tests revealed severe metabolic alkalosis ( ph 7.56 ) with low potassium ( 2.7 mmol / l ) , hypochloremia ( < 60 mmol / l ) , increased hematocrit ( 53% ) and high levels of serum creatinine ( 651 mol / l ) . 
 based on a history of recurrent vomiting , gastroscopy and computed tomography were performed . 
 both diagnostics showed an upside - down stomach with signs of incarceration . upon infusion of sodium chloride 0.9% , acid - base state , electrolyte balance and renal function became improved . 
 subsequently , the patient was referred to the department of surgery for hiatoplasty with fundoplication . 
 this case report highlights severe metabolic and neurological disorders as unusual and life - threatening complications of an upside - down stomach .