Healed Gastric Ulcer with Associated Inflammatory Fibrotic Changes in a Diaphragmatic Hernia

Abstract

In reviewing the literature Bright (2), in 1836, recorded the first case of a gastric ulcer involving a diaphragmatic hernia with death from exhaustion after a long period of vomiting and dyspnea. Collier, Hurst, and Sheaf (3) in 1929 reported two more cases from Guy's Hospital, both in males. Mathews and MacFee (18) in 1931 reported fifteen cases of hernia in women from forty to fifty-eight years of age; all but one of this group were fairly obese, and such blood counts as were available showed anemias of varying degree. In two instances ulcers were present on the lesser curvature at the point where it was in contact with the constricting margin of the diaphragm. Few of the cases reviewed exhibited typical symptoms of ulcer, and for the most part the ulcer was unsuspected, being found either at operation or autopsy; some were even overlooked at operation. Diaphragmatic hernia ulcers are, as a rule, superficial erosions (9“10) that do not penetrate the stomach wall. The pressure exerted on the vascular supply by the margins of the hernial opening is a factor in the occurrence of these ulcer erosions (15“19). This constricting pressure produces congestion, varicosities and disturbance of the arterial supply, followed in some instances by secondary infection and subsequent fibrosis of the surrounding stomach and esophageal wall. This latter finding was recorded by Morrison and Jones of Boston (19) and was suggested as a possible explanation for hematemesis or melena. Ulcers occur for the most part on the lesser curvature, a predisposing factor being stagnation of gastric contents which are thus afforded an opportunity to act on the gastric mucosa. The first evidence of the condition is mild epigastric distress most noticeable after a heavy meal and relieved by belching or vomiting. Attacks become more severe as more of the stomach becomes incorporated in the hernia, with pain radiating to the back, usually to the left of the spine. Pain may become agonizing on account of spasm of the diaphragm and reflex cardiospasm. It may even simulate a cardiac condition (12). In the later stages weakness and shortness of breath are prominent symptoms. Key (16) reports a case of gastric ulcer in a diaphragmatic hernia cured by operation, and Nord (20) reports one successfully treated by phrenic neurectomy. In the case to be reported here an ulcer was suspected on fluoroscopic examination, and a healed gastric ulcer site was verified postmortem, microscopic sections showing resultant damage in the way of fibrosis and thickening of the tissues and muscular structures of the diaphragmatic portion of the stomach and adjacent esophagus. Case Report J. C., a 62-year-old white man, was admitted July 20, 1937, with a two-year history of difficulty in swallowing, first of solid foods and within the past month even of liquids. Regurgitation was a prominent symptom.