Background:Syncope is a transient loss of consciousness,associated with loss of postural tone,with spontaneous return to baseline neurologic function requiring no resuscitative efforts.The underlying mechanism is a global hypoperfusion of both the cerebral cortices or focal hypoperfusion of the reticular activating system. Case report:A 74 year old female had sudden loss of consciousness after eating meal and after an physical effort. This condition was proceded by nonsense talking,unpleasant and warmth feeling. A careful history is taken by an witness and a detailed physical examination was done but did not revealed any cause of syncope.She was presented at the emergency department in postsyncope phase with confusion,takipnea,pallor,vomiting, profuse sweating. No injury was founded. We founded normal sinus rhythm puls rate 76/min with arterial pression 130/90 mmHg. Lung auscultation revealed crackling sounds and a slight down saturation peripheral oxygenation Sp0292% that arise a suspicion of aspiration pneumonia.A detailedneurologic examination was done and the patient was conscious,without limbs deficits, pupils was with a normal size. A chest X-Ray was performed and after this a chest Fluoroscopy in advance which was essential to make diagnosis.There was an large retrocardiac opacity with air and liquid level compatible with a giant hiatus hernia. This can cause syncope by impeding blood flow from left atrium to the left ventricle decreasing cardiac output as the sole mechanism of syncopal episode.The total blood account and complete metabolic panel was normal. An ECG with 12 lead was performed that showed sinus rhythm. Abdominal echography was normal. Two dimensional echocardiography demonstrated cardiac parameters within normal limits.The diagnosis is confirmed with thoracic-abdominal computed tomography. There was a huge hiatal hernia with air-fluid level behind the heart in close relation to the left atrium.Patient was hospitalized in the intensive care unit for further examinations and treatments because after 3 hours she had an episode of fever 38.5 grade celcius and cough due to aspiration pneumonia.She was treated with antibiotics(ceftriaxione),omeprazole,metoclopramide etc and after 7 days she was referred to another hospital for surgery treatment. Discussion:Differentiating true syncope from “non‐syncopal” conditions associated with real or apparent transient loss of consciousness is generally the first diagnostic challenge and influences the subsequent diagnostic strategy. The absence of signs of suspected heart disease excludes a cardiac cause of syncope. Neurologic disease may cause transient loss of consciousness (for example, certain seizures), but is almost never the cause of syncope. Learning points:Neurally‐mediated reflex syncopes have “non‐classical” presentations.These forms are diagnosed by minor clinical criteria, exclusion of other causes for syncope (absence of structural heart disease).We present a rare case of the situational syncope triggering from gastrointestinal stimulation and physical efforts caused by huge hiatal hernia.
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