An X-ray Sign in the Diagnosis of Reducible Esophageal Orifice Hernia

Abstract

THERE has been an increasing interest in diaphragmatic hernias during the past few years. This is due, in part, to the fact that the clinical manifestations of the condition are manifold, often simulating and being mistaken for other, and usually more serious, intra-abdominal conditions. There is also a growing suspicion among some clinicians that diaphragmatic hernias may sometimes cause a severe, obscure anemia. The literature has now assumed sizable proportions. The clinical, developmental, and roentgen features have been well considered at length. Most of the recent observers stress the point that diaphragmatic hernias, particularly those through the hiatus, are still being overlooked in spite of the wide use of x-ray methods. These authors also call attention to the importance of a thorough examination in the various horizontal positions, if this condition is suspected. Owing to the limitations of time, space, and apparatus, many small laboratories, and not a few of the larger clinics, do not make such studies routinely. Moreover, some diaphragmatic hernias, even in the horizontal position, can be demonstrated only by prolonged and repeated examination. The importance of the lesion does not warrant making such a long-drawn-out routine search with all gastro-intestinal cases in a busy clinic. Any sign in the vertical position calling attention to the possibility of a diaphragmatic hernia should be of value. Gray, discussing the comprehensive article of Ritvo, suggested that it is absolutely impossible to diagnose or even suspect reducible orifice hernias with the patient in the vertical position. This is the type most apt to be overlooked during the roentgen examination, at the operating table, and even during the postmortem. The esophagus in the lower third forsakes its close relation with the spine, curving laterally and forward to pass through the hiatus esophagi of the diaphragm, and thence to reach the stomach at a rather acute angle. This portion of the esophagus is normally capable of respiratory motion, traveling to the midline and forward on inspiration. The stomach, which hugs the medial half of the diaphragm closely, is in an excellent position to herniate, if there be an opportunity to do so. The stomach migrates downward, as does the diaphragm, and the esophagus lengthens to permit this descent. Failure of the esophagus to do so for any reason causes a portion of the stomach to extend through the diaphragm. This hernia, known as the short esophagus type, has been well described by Akerlund and Anderson. If the patient assumes an upright position, there is no opportunity for a reduction. This hernia is excessively rare and has identifying characteristics of its own.