Postgraduate Medical Journal (1986) 62, 325-327 Postgrad Med J: first published as 10.1136/pgmj.62.727.325 on 1 May 1986. Downloaded from Leading Article Diaphragmatic hernia - a diagnostic challenge Harold Ellis Surgical Unit, Westminster Hospital, London SWI, UK.

Introduction Clinical syndromes and their aetiology Hernias through the diaphragm are a fascinating The great majority ofsliding hiatus hernias are entirely group ofconditions - some extremely common, others symptomless. This important statement cannot be exquisitely rare - whose wide spectrum of clinical over-emphasized. It has already been noted that more manifestations, diagnostic difficulties and problems of than half the elderly population in the Western world treatment render them of great interest to gastroen- would have some degree of hiatus hernia if submitted terological physicians, radiologists, endoscopists, clin- to a barium meal examination. It is a serious mistake ical physiologists and surgeons, as well as to the to attribute symptoms such as chest pain, epigastric general practitioner. discomfort, dysphagia etc. to a sliding hiatus hernia demonstrated radiologically without excluding other causes - functional as well as organic. Classification Reflux oesophagitis, which is the cause ofthe heart- burn especially associated with bending and lying, is The commonest situation is when the cardia slides due not so much to the hernia as to incompetence of through the oesophageal hiatus into the mediastinum the sphincter at the oesophago-gastric junction. This

(the sliding hernia); less commonly, the gastro-oeso- sphincter is a physiological barrier which can be copyright. phageal junction remains in its correct position with demonstrated by manometric measurements, which the gastric fundus rolling alongside it through the reveal the existence of a zone of high pressure whose hernia into the thoracic cavity (the rolling or para- function is modified by nervous and hormonal stimuli. oesophageal hernia) while in some cases the two At this level there is no definite anatomical sphincter. conditions co-exist. A number of rare congenital It is true that 60 to 90% of patients with reflux oeso- hernias may occur; through the foramen ofMorgagni, phagitis have a concomitant hiatus hernia (Bombeck, situated anteriorly between the xiphoid and costal 1978) but reflux can occur in the presence ofan entirely origins of the diaphragm, through the foramen of normal hiatus. The physiopathology of reflux oeso- http://pmj.bmj.com/ Bochdalek, representing the embryological pleuro- phagitis is still only incompletely understood and may peritoneal canal, lying posteriorly in the diaphragm, be due to multiple and often complex causes, including and occasionally through a congenital deficiency of incompetence of the inferior oesophageal sphincter, the whole central tendon of the diaphragm. Rarely, incomplete oesophageal clearance, diminution in the trauma may rupture the diaphragm and this may lead mucosal defences ofthe oesophagus and the aggressive to a traumatic diaphragmatic hernia. nature ofthe refluxing material. It is important to note Hiatus hernia is extremely common in the Western that the size of the sliding hiatus hernia is also not world with a prevalence some 50 to 100 times greater related to the symptoms. The symptoms of reflux are on September 23, 2021 by guest. Protected than exists in Africa and Asia. Although equally aggravated not only by posture but by obesity, distributed between the two sexes, symptomatic hiatus wearing tight garments, ingestion of alcohol or acid hernia is at least twice as frequent in the female. All foods; frank regurgitation of bitter gastric contents ages may be affected, but the incidence rises with each into the mouth may occur. decade until, in the elderly, it is present radiologically As inflammation becomes more severe, ulceration in some 60% of the population. of the lower oesophagus may occur with painful Reviews oflarge series ofcases show that the sliding dysphagia and there may be progression to fibrous hernia occurs in the order of 75% of cases, the para- stricturing of the lower oesophagus. Here, of course, oesophageal hernia in 20% and the mixed variety in the differential diagnosis must be made from other 5% (Hollender & Meyer, 1984). causes of dysphagia in adults - achalasia and, par- ticularly, carcinoma ofthe lower oesophagus or ofthe cardia; this is achieved by careful barium meal studies Correspondence: Professor H. Ellis, D.M., M.Ch., F.R.C.S. and by endoscopy with biopsy of the stricture. Received: 2 December 1985 Reflux oesophagitis as a cause of a frank gastroin- ) The Fellowship of Postgraduate Medicine, 1986 326 H. ELLIS Postgrad Med J: first published as 10.1136/pgmj.62.727.325 on 1 May 1986. Downloaded from testinal haemorrhage is rare and great caution should 1971). The volvulus may be acute, when it presents as be observed before attributing the one to the other an abdominal emergency with either obstruction or without carefully excluding other possible causes of actual strangulation of the stomach. Gangrene may the haemorrhage. occur but is uncommon because of the particularly The lack of correlation between the anatomical rich blood supply to the stomach. Much more com- defect ofthe sliding hiatus hernia and the symptoms of monly, the volvulus is chronic or recurrent and indeed reflux oesophagitis is well illustrated by the fact that may present as an incidental radiological finding on a today surgical correction ofthe defect concentrates on barium meal or chest X-ray. When symptoms occur, anti-reflux measures, such as the Nissen (1956) fundo- they are frequently those of mild, continuous or plication operation, since mere repair of the hiatus intermittent upper abdominal discomfort which may hernia itself so often proved unsatisfactory in the past be impossible to differentiate from a peptic ulcer or (Battle & Bombeck, 1973). cholecystitis. The patient may complain of distress or Unlike a sliding hiatus hernia, where the symptoms bloating during or shortly after meals, which may be are primarily the result of deranged physiology at the followed by retching or vomiting. Ifa good deal ofair oesophago-gastricjunction, the symptoms ofthe para- or fluid has been swallowed, the distended and volved oesophageal hernia result from its anatomy. The stomach may prevent belching of the air or vomiting herniated stomach passes through a markedly and the patient may simply bring up white frothy widened hiatus and lies in a peritoneal sac between the swallowed saliva. oesophagus behind and the pericardium in front. Most Acute volvulus presents a striking clinical picture patients, surprisingly, are asymptomatic, the diagnosis with severe epigastric pain and distension, vomiting only being made when a routine chest radiograph followed by violent retching with an inability to vomit demonstrates a large gas bubble in the mediastinum. and difficulty or inability to pass a nasogastric tube. Others present with vague discomfort after food, sub- There may be minimal abdominal signs when the sternal fullness, nausea, vomiting and sometimes volved stomach is in the chest but a gas filled viscus in dyspnoea due, presumably, to the presence of a large the lower chest or upper abdomen is shown by chest intra-thoracic 'space occupying lesion'. Symptoms of radiography, especially when associated with a para- reflux and regurgitation do not occur unless there is an oesophageal hiatus hernia. Carter and his colleagues associated gastro-oesophageal sphincter defect. (1980) give an important review of acute gastric copyright. Other symptoms are related to complications ofthe volvulus and found that gangrene occurred in seven of rolling hernia. Chronic blood loss with the develop- their 25 cases. Hooper & Lawson (1986) have recently ment ofa microcytic anaemia may occur due either to reported a unique case ofpulsus paradoxus associated an erosive gastritis as a result of venous stasis in the with a strangulated volvulus through a previous herniated portion of the stomach or, less commonly, traumatic tear of the diaphragm. to an ulcer at the neck of the hernia. Acute complica- When symptoms of recurrent volvulus are disa-

tions include a massive haemorrhage due to this peptic bling, operative repair may be indicated. Acute http://pmj.bmj.com/ ulceration and, very exceptionally, perforation ofsuch volvulus can sometimes be reduced by the passage ofa an ulcer may occur into the mediastinum or into the nasogastric tube but more frequently a tube cannot be pleural or pericardial cavity (Monro et al., 1974). passed and immediate surgery is mandatory. The Strangulation of the herniated part of the stomach volvulus is reduced surgically if possible and if gastric with gangrene is an extremely rare complication (Hill, necrosis has taken place, local excision, sub-total 1973). gastrectomy or even total resection may be required.

Gastric volvulus Traumatic hiatus hernia on September 23, 2021 by guest. Protected An interesting but relatively unusual complication of Rupture of the diaphragm may follow penetrating or diaphragmatic hernia, usually of the rolling type but crush injuries but may also occur following heavy also complicating traumatic or congenital defects, is physical effort, sudden twisting movements, childbirth volvulus ofthe stomach (Ellis, 1984). In this condition, or a coughing fit (Bisgaard et al., 1985). These all volvulus occurs usually along a line from the pylorus probably cause a sudden increase in abdominal pres- to the oesophago-gastric junction (organo-axial sure resulting in a pressure gradient across the dia- volvulus) while less often it occurs around the axis that phragm. Because ofthe protective effect ofthe liver, it runs from the centre of the greater curvature of the is nearly always the left hemi-diaphragm which is stomach to the porta hepatis (mesentero-axial implicated. The tear may be undetected for many years volvulus). In our review of over 200 cases of this and then be complicated by herniation of abdominal condition, organo-axial volvulus occurred in 59%, contents into the left hemi-thorax with subsequent mesentero-axial in 29%, 2% were combined and the strangulation; the stomach, greater omentum and remaining 10% were not classified (Wastell & Ellis, colon are most particularly at risk. McIndoe & DIAPHRAGMATIC HERNIA 327 Postgrad Med J: first published as 10.1136/pgmj.62.727.325 on 1 May 1986. Downloaded from

Hopkins (1986) have recently reviewed this interesting and interesting group ofconditions, ranging from the topic and present an example of spontaneous rupture extremely common sliding hernias to rare congenital ofthe left diaphragm in a young man following heavy and traumatic cases. The clinical features also vary digging. The herniated stomach underwent necrosis from incidental findings at radiology, laparotomy or and perforation but recovery followed partial gastrec- autopsy to life-threatening emergencies. They enter tomy and repair of the diaphragmatic tear. into the differential diagnosis of the other acute and chronic upper gastrointestinal pathologies, intrath- oracic diseases and functional conditions. Conclusion Hernias through the diaphragm constitute a varied

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