Bloating & Pain

A 46-year-old woman was seen in November, 1953, with complaints of episodes of dysphagia for six years, gas and bloating for three years, and constipation of many years' duration. For the previous six years, at intervals of every two to four weeks, bits of ingested food had lodged in the mid-substernal area; these attacks had been followed by an acute, severe pain radiating to the epigastrium and upper left quadrant. The pain lasted for from 20 minutes to four hours; it was referred to the left infraclavicular area and down the left arm to the fingers as it subsided. 

Complete physical examination was essentially normal. Laboratory studies showed moderate hypochromic anaemia, the haemoglobin being 9.0 gm., with a cell volume of 32 c.c. Stool examination, urinalysis, blood sugar, gastric acidity and serology were negative or normal. Roentgen examination of the chest showed the right lung field to be normal. The left leaf of the diaphragm was not definitely identified; the shadow of the abdominal viscera was visible in the left lower chest to the level of the fourth anterior rib (figure 1). The gallbladder was normal. On barium examination, a portion of the stomach was found above the diaphragm. 

Barium enema examination (figure 2) showed the splenic flexure of the colon to be in the thorax, extending 10 cm. above the diaphragm, and the cecum to be inverted, with a very short ascending colon. At operation on January 4, 1954, approximately two months after the initial examination, a large para-oesophagal hiatus hernia and an oesophagus of normal length were found. Almost the entire stomach and the splenic flexure of the colon were present in the thorax. The hiatus of the diaphragm admitted the surgeon's fist. 

The stomach and colon were replaced in the abdominal cavity, and the large hiatus was repaired. The patient's postoperative course was uneventful, and she was discharged on January 13, 1954. The Roentgenogram of the chest postoperatively was normal. When seen six weeks after the operation, she had experienced no further discomfort.