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Diaphragmatic Hernia as a Cause of “Intractable Heartburn” of Pregnancy
DIAPHRAGMATIC HERNIA AS A CAUSE OF ''INTRACTABLE HEARTBURN" OF PREGNANCY
T
ilE sut·prising in,·i,lPllt'l\ n1· l'il!li•·r·. th<· grvatl,l ·,iii'l'l'il"'''i of diaguosis. of diaphragnra1 t(· l!('l'l!in in tl~o· pa~l. 1\\ '' d"''iHlPs h
lllllll hf'r of P<• IH'I'" !Ill t IH· ~1.t'iit•r:t l Th""' l'H<'ntg·<:'nologish; whu han· ht>•·ol•••· ·· diaphi·:t!!'!ltn1 i<· hl'JTtin •~rilid<·d have been ahle to :-;ol\·,. nwny a ktJP1iy diag11u"1i•· pr•.ld,·Jll hy 1l:•· dt·Ju
or·,·asioned a lan;P
on:;;tration of su•·h a h1·1·nia. Oh:-:.·w·,. s.\lltpt .. n•s ,., (,.t·:thJ,. 1<• 11H· :2::tslr·'·' intestinal t1·ael. tlH• hilial'y syslt·tJI "~' 11!1· <·:tt·diuJ·;·spinttory :-yst<·IJI h1l\•' disapp<'m·ed following sm·;.!.'i<·al ~'"Jlrnia in I'OUghJy !110 oHi nf ]00 patit'lllS, Howevl'l'. wlwn dt·ttll·d indtletH'(' was 12.1' pt•l' ('('ilL Of ]P positin· I':ISI'', o'('·I'Xlllilllli'd ::i'lt'! drliYery, tlw ltPl'llin t·tntid lw r.·dt·!JHtth. 1;1·•·;~• <'.ill'!:' \·\'Hs takt·!l 1<~ distingniNh IH·ll\t'Pil diaphragiJt:tli•· h<·rtti
nl'
11
hi'l'tll(l
\.,
SJI(·iJ
l'u!Tt'i;llloll
t·
lw
d1·
tPJ'Illilled. (ltl lilt• i'IHill' ]l,Vt'oHiN a11d g:ast ri•· disi l'<'ss in 1!J.,.,p indi1·idual,; 11 '"' :-:ho''' d -.:11npl• regurgitation into 11H· •·orit·d '' p
fatal rasl's in 1111' lit,•ratnt'l'. 11 is ;tpp:il'l'll1 1hat a diapht·nuuull i•· IH·I'rtl<• in a pregnant wuntatl lllllst ],.. ,..,n.,ilh. c•speeially wlwn portilltls ol' 1h•· "!"!"111im,i \·is•·<·!';t "'h•·r 1hn11 11,, . ..;Jnllt aeh m·p im.Judt·d in thl' lwrnia.
11 is wt>ll kno\\'n 1hnl diapltl';t'.!llt:tli•· ll!•rni:J <·:111 t'llll~•· s.\ iltp1niH:' t'PSI'llllilinc; thos1· !'l!
t~ .•
l', R.
\nuy Air l::l'nn't'
SCHNEPP:
HER::>TiA CAUSING HEARTBuRN IN PREGNANCY
143
unexplained anemias, 6 or anomalous cardiac symptoms, frequently postprandial and relieved by vomiting but not by food, have been symptom complexes solved in certain instances only hy the discovery of an hiatus hernia. This protean nature of the clinical picture led Hedblom7 to state: ·'The etiology of diaphragmatic hernia is often ohscu:re, its pathologic anatomy diversified, and its clinical manifestations 1n1l1ifold.'' ~' '~tven though it is admitted that an appreciable percentage of dia1phmgmatic hernias may be symptomless, it would seem strange not to find symptoms of such a functional and anatomic defect as this, shown as it is to be unusually common in the pregnant woman. One would expect such symptoms in particular to be precipitated during the stress and strain of labor. Reports of such complications are not common. A case is recorded 8 of emesis of blood twice during a twenty-seven-and-one-half-hour labor in a patient without previous gastric symptoms. Labor was terminated by forceps. Occasional heartburn after delivery led to roentgenologic examination of the stomach which revealed one-fourth of this organ above the diaphragm. D(.;Lee and Gilson 9 report the partial strangulation of the viscera in a dil\>hragmatic hernia during the puerperium. This case was apparentlJ'not checked by roentgenologic examination. Evans and Bouslog 10 have recently reported four cases, termed 1 ' intractable heartburn of pregnancy," and characterized by severe epigastric distress or burning, appearing after the twentieth week of pregnancy, unrelieved by the usual gastric medication and usually aggravated by the recumbent position. Following delivery, the distress disappeared promptly and the herniation causing it conld not be again demonstrated. In aU probability, diaphragmatic herniation of part of the stomach in the pregnant woman is responsible for more epigastric distress and pain than is realized. In retrospect, it is easy to recall an occasional patient who did not respond to the usual gastric remedies and in whom adequate roentgenologic study might have revealed an hiatus hernia. The tendency is to ascribe these symptoms to aberrant function, or to enlargement of the ute1·us with a resulting mechanical displacement of the abdominal viscera. This view is encouraged by the disappearance il>f distress post partum. [.· The possibility that this might be a relatively frequent but often tmdiscovered symptom conelation justifies the publication of the following case.
Case Report Mrs. B. :McC. (No. 2186), born Aug. 3, 1917, was first seen in the present illness on Nov. 25, 1941. The patient's last menstrual period had occurred Sept. 20, 1941, and she complained of nausea, pain in the back, and headaches. Onset of menses had occurred at approximately twelve years of age and had been somewhat irregular with a duration of five to seven days. A first pregnancy had resulted in miscarriage (said to have been spontaneous) at two months in :M:ay, 1938. Curettage was performed for retained placental tissue at Springfield (lllinois) HospitaL A second pregnancy terminated in the spontaneous delivery
144
AMERICAN .JOl:RNAL OF Oll~TETRICS AND UYl\' ;;:coLOGY
of a living male infant aftet· a 11ineteen-hour labor. Oestation and puerperium wet·e apparently uneventful. The past medieal history included mea::,;les, mumps, ehickenpox. and pertussis as a ehild. Ko serious illness had eY<'t' orc•mreg-ative.
Fig. 1.-Film of the case reported. taken in a moderate Trendelenburg posi,ion, a nd r evealing a portion of th e s t omach abow the diaphragm and passing through the esophageal hia tus.
Upon physical examination, the weight was 134 pounds and blood pressure 124/70. Urine examination was negative (and subsequently remained so). Head, chest, abdomen, and reflexes were normal. The .blood Kahn and Eagle were both negative. The perineum had been markedly lacerated. The cervix was moderately lacerated, ulcerated and nodular. The fundus was softened and slightly enlarged. Adnexa were negative to palpation.
SCHNEPP:
HERNIA CAUSING HEARTBURN IN PREGNANCY
145
The course of the pregnancy was for the most part uneventful. Life was noticed about Jan. 21, 1942. Blood pressure dropped to 85/50 and remained low. During the first part of 1\farch, 1942 (approximately the twenty-third week), a moderately severe but intermittent epigastric pain appeared. \Vithin two weeks the pain had become more constant, bore no constant relationship to food and seemed to be aggravated by lying down. It would awaken her at nig·ht and often would be relieved by assuming the erect position. Nausea was infrequent and the relatively few vomiting attacks did not always bring relief. Belching would eelieve only at times. Various antacids and gastric sedatives were tried without relief. By May 6, 1942, the uterus >vas 6 em. above the umbilicus and the head engaged. The blood pressure was 82/50. The weight had remained at about 143 pounds for several weeks. Roentgenologic examination (Dr. D. lVL Sirca) on May 8, 1942, revealed an hiatal hernia (l1g. 1). This film was obtained in the moderate Trendelenburg position. Further fluoroscopic observation identified gastric mucosa above the diaphragm. During May, 1942, th~ pain at times was quite severe and the patient was unable to obtain adequate rest at night. Because of the increasing severity of symptoms, induction of labor was advised and the membranes were ruptured artificially at 5 :45 P.M. on May 26, 1942, in St. John's Hospital (Springfield, Illinois) about one month ahead of term. Sporadic contractions occurred next day and during the evening of May 27 the patient had an emesis of coffee-groundlike material. Labor began definitely about 2 :00 A.M. on 1\fay 28. During the ensuing morning, two further emeses occurred, both made up largely of dark brown blood. At 12 :30 P.M. on May 28, 1942, a living male child, weight 5 pounds 14 ounces, was delivered spontaneously. The puerperium was marked by the disappearance of all epigastric pain by the fourth day and the patient since has remained symptom free. Strenuous efforts to demonstrate the hiatus hernia roentgenologically three weeks post partum were unsuccessful.
Conclusions 1. Diaphragmatic hernia is being diagnosed with an ever increasing frequency and has been proved to be the cause of a wide variety of symptoms. 2. Under conditions of general practice, symptoms sufficient to bring the patient to the roentgenologist for examination will reveal a diaphragmatic hernia in about two out of 100 patients. 3. It has been pointed out that "intractable heartburn" of pregnancy, appearing .after the twentieth week, unrelieved by the usual gastric medication and usually aggravated by the recumbent position, may well constitute a rarely recognized symptom of diaphragmatic hernia.
References I.
2. 3. 4. 5. 6.
Hedblom, C. A.: Ann. Sur g. 94: 776, 1931. Schnepp, K. H.: Illinois M. J. 83: 404, 1943. Rigler, L. G., and Eneboe, J. B.: J. 'rhoraeic Surg. 4: 262, 1935. Didd~e, A. W., and Tidrick, R. T.: AM. J. OnsT. & GYNEC. 41: 317, 1941. Rarrmgton, S. W.: Am. J. Surg. 50: 381, 1940. Bock, A. V., Dulin, J. W., and Brooke, P .•1\.: New England J. Med. 209: 615, 1933.
146
AMERICAN ,JOUR~AL
A.
MURPHY,
M.D.,
BOSTON, MASS.
(From the Gynecologicnl nnd Obstetriml 8ervioe of the Bo8ton Oity Hospital)
the most important advances in the field of estrogen therapy 0 NEin ofrecent years was the discovery that synthetic chemical compounds, structurally unrelated to the natural occurring steroid hormones, were sufficiently estrogenic and free from toxicity to warrant their clinical use. These compounds had the advantage of being effective when administered orally. Since 1938, when Dodds, Lawson, and Noble1 reported the high estrogenic activity of diethylstilbestrol, many reports of its use have appeared in the literature. A recent review by MorrelP and the report of the Council on Pharmacy and Chemistry" would seem to make an extensin' reference to thiR literature unnee!'ssary here. Although permanent damage has n£•ver been established on the basis of blood, urine and liver function tests, the incidence of untoward side reactions following the administration of diethylstilbestrol cannot be completely ignot·ed. I wish to report my results ·with a new synthetic estrog·en, not a derivative of stilbestrol, with which J have done extensive clinical work. The compound has the trade name Oetofollin,<~< and is a 2,4-di(parahydroxyphenyl)-3-ethyl hexane. I1 has the following chemical configuration. CH-CII
CH
t ~II"
CH,
CH"
CH,
CH,,
1
i
It might be mentioned here that it is impossible to write this chemical
formula in any way to resemble the natural estrogen, as could be done with diethylstilbestrol. Clinical results upon a selected group of menopause patients treated with this substance, then called 118 B, have been reported by F'reed, Eisin, and Greenhill.), 5 The chemical researches leading to the development of this estrogen and the physiologic work demonstrating its efficacy and safety have been reported.e-s *Product of the Research Laboratories ot Schiet'felin & Co., New York.
T
ilE sut·prising in,·i,lPllt'l\ n1· l'il!li•·r·. th<· grvatl,l ·,iii'l'l'il"'''i of diaguosis. of diaphragnra1 t(· l!('l'l!in in tl~o· pa~l. 1\\ '' d"''iHlPs h
lllllll hf'r of P<• IH'I'" !Ill t IH· ~1.t'iit•r:t l Th""' l'H<'ntg·<:'nologish; whu han· ht>•·ol•••· ·· diaphi·:t!!'!ltn1 i<· hl'JTtin •~rilid<·d have been ahle to :-;ol\·,. nwny a ktJP1iy diag11u"1i•· pr•.ld,·Jll hy 1l:•· dt·Ju
or·,·asioned a lan;P
on:;;tration of su•·h a h1·1·nia. Oh:-:.·w·,. s.\lltpt .. n•s ,., (,.t·:thJ,. 1<• 11H· :2::tslr·'·' intestinal t1·ael. tlH• hilial'y syslt·tJI "~' 11!1· <·:tt·diuJ·;·spinttory :-yst<·IJI h1l\•' disapp<'m·ed following sm·;.!.'i<·al ~'"Jl
nl'
11
hi'l'tll(l
\.,
SJI(·iJ
l'u!Tt'i;llloll
t·
lw
d1·
tPJ'Illilled. (ltl lilt• i'IHill'
fatal rasl's in 1111' lit,•ratnt'l'. 11 is ;tpp:il'l'll1 1hat a diapht·nuuull i•· IH·I'rtl<• in a pregnant wuntatl lllllst ],.. ,..,n.,i
11 is wt>ll kno\\'n 1hnl diapltl';t'.!llt:tli•· ll!•rni:J <·:111 t'llll~•· s.\ iltp1niH:' t'PSI'llllilinc; thos1· !'
t~ .•
l', R.
\nuy Air l::l'nn't'
SCHNEPP:
HER::>TiA CAUSING HEARTBuRN IN PREGNANCY
143
unexplained anemias, 6 or anomalous cardiac symptoms, frequently postprandial and relieved by vomiting but not by food, have been symptom complexes solved in certain instances only hy the discovery of an hiatus hernia. This protean nature of the clinical picture led Hedblom7 to state: ·'The etiology of diaphragmatic hernia is often ohscu:re, its pathologic anatomy diversified, and its clinical manifestations 1n1l1ifold.'' ~' '~tven though it is admitted that an appreciable percentage of dia1phmgmatic hernias may be symptomless, it would seem strange not to find symptoms of such a functional and anatomic defect as this, shown as it is to be unusually common in the pregnant woman. One would expect such symptoms in particular to be precipitated during the stress and strain of labor. Reports of such complications are not common. A case is recorded 8 of emesis of blood twice during a twenty-seven-and-one-half-hour labor in a patient without previous gastric symptoms. Labor was terminated by forceps. Occasional heartburn after delivery led to roentgenologic examination of the stomach which revealed one-fourth of this organ above the diaphragm. D(.;Lee and Gilson 9 report the partial strangulation of the viscera in a dil\>hragmatic hernia during the puerperium. This case was apparentlJ'not checked by roentgenologic examination. Evans and Bouslog 10 have recently reported four cases, termed 1 ' intractable heartburn of pregnancy," and characterized by severe epigastric distress or burning, appearing after the twentieth week of pregnancy, unrelieved by the usual gastric medication and usually aggravated by the recumbent position. Following delivery, the distress disappeared promptly and the herniation causing it conld not be again demonstrated. In aU probability, diaphragmatic herniation of part of the stomach in the pregnant woman is responsible for more epigastric distress and pain than is realized. In retrospect, it is easy to recall an occasional patient who did not respond to the usual gastric remedies and in whom adequate roentgenologic study might have revealed an hiatus hernia. The tendency is to ascribe these symptoms to aberrant function, or to enlargement of the ute1·us with a resulting mechanical displacement of the abdominal viscera. This view is encouraged by the disappearance il>f distress post partum. [.· The possibility that this might be a relatively frequent but often tmdiscovered symptom conelation justifies the publication of the following case.
Case Report Mrs. B. :McC. (No. 2186), born Aug. 3, 1917, was first seen in the present illness on Nov. 25, 1941. The patient's last menstrual period had occurred Sept. 20, 1941, and she complained of nausea, pain in the back, and headaches. Onset of menses had occurred at approximately twelve years of age and had been somewhat irregular with a duration of five to seven days. A first pregnancy had resulted in miscarriage (said to have been spontaneous) at two months in :M:ay, 1938. Curettage was performed for retained placental tissue at Springfield (lllinois) HospitaL A second pregnancy terminated in the spontaneous delivery
144
AMERICAN .JOl:RNAL OF Oll~TETRICS AND UYl\' ;;:coLOGY
of a living male infant aftet· a 11ineteen-hour labor. Oestation and puerperium wet·e apparently uneventful. The past medieal history included mea::,;les, mumps, ehickenpox. and pertussis as a ehild. Ko serious illness had eY<'t' orc•mre
Fig. 1.-Film of the case reported. taken in a moderate Trendelenburg posi,ion, a nd r evealing a portion of th e s t omach abow the diaphragm and passing through the esophageal hia tus.
Upon physical examination, the weight was 134 pounds and blood pressure 124/70. Urine examination was negative (and subsequently remained so). Head, chest, abdomen, and reflexes were normal. The .blood Kahn and Eagle were both negative. The perineum had been markedly lacerated. The cervix was moderately lacerated, ulcerated and nodular. The fundus was softened and slightly enlarged. Adnexa were negative to palpation.
SCHNEPP:
HERNIA CAUSING HEARTBURN IN PREGNANCY
145
The course of the pregnancy was for the most part uneventful. Life was noticed about Jan. 21, 1942. Blood pressure dropped to 85/50 and remained low. During the first part of 1\farch, 1942 (approximately the twenty-third week), a moderately severe but intermittent epigastric pain appeared. \Vithin two weeks the pain had become more constant, bore no constant relationship to food and seemed to be aggravated by lying down. It would awaken her at nig·ht and often would be relieved by assuming the erect position. Nausea was infrequent and the relatively few vomiting attacks did not always bring relief. Belching would eelieve only at times. Various antacids and gastric sedatives were tried without relief. By May 6, 1942, the uterus >vas 6 em. above the umbilicus and the head engaged. The blood pressure was 82/50. The weight had remained at about 143 pounds for several weeks. Roentgenologic examination (Dr. D. lVL Sirca) on May 8, 1942, revealed an hiatal hernia (l1g. 1). This film was obtained in the moderate Trendelenburg position. Further fluoroscopic observation identified gastric mucosa above the diaphragm. During May, 1942, th~ pain at times was quite severe and the patient was unable to obtain adequate rest at night. Because of the increasing severity of symptoms, induction of labor was advised and the membranes were ruptured artificially at 5 :45 P.M. on May 26, 1942, in St. John's Hospital (Springfield, Illinois) about one month ahead of term. Sporadic contractions occurred next day and during the evening of May 27 the patient had an emesis of coffee-groundlike material. Labor began definitely about 2 :00 A.M. on 1\fay 28. During the ensuing morning, two further emeses occurred, both made up largely of dark brown blood. At 12 :30 P.M. on May 28, 1942, a living male child, weight 5 pounds 14 ounces, was delivered spontaneously. The puerperium was marked by the disappearance of all epigastric pain by the fourth day and the patient since has remained symptom free. Strenuous efforts to demonstrate the hiatus hernia roentgenologically three weeks post partum were unsuccessful.
Conclusions 1. Diaphragmatic hernia is being diagnosed with an ever increasing frequency and has been proved to be the cause of a wide variety of symptoms. 2. Under conditions of general practice, symptoms sufficient to bring the patient to the roentgenologist for examination will reveal a diaphragmatic hernia in about two out of 100 patients. 3. It has been pointed out that "intractable heartburn" of pregnancy, appearing .after the twentieth week, unrelieved by the usual gastric medication and usually aggravated by the recumbent position, may well constitute a rarely recognized symptom of diaphragmatic hernia.
References I.
2. 3. 4. 5. 6.
Hedblom, C. A.: Ann. Sur g. 94: 776, 1931. Schnepp, K. H.: Illinois M. J. 83: 404, 1943. Rigler, L. G., and Eneboe, J. B.: J. 'rhoraeic Surg. 4: 262, 1935. Didd~e, A. W., and Tidrick, R. T.: AM. J. OnsT. & GYNEC. 41: 317, 1941. Rarrmgton, S. W.: Am. J. Surg. 50: 381, 1940. Bock, A. V., Dulin, J. W., and Brooke, P .•1\.: New England J. Med. 209: 615, 1933.
146
AMERICAN ,JOUR~AL
A.
MURPHY,
M.D.,
BOSTON, MASS.
(From the Gynecologicnl nnd Obstetriml 8ervioe of the Bo8ton Oity Hospital)
the most important advances in the field of estrogen therapy 0 NEin ofrecent years was the discovery that synthetic chemical compounds, structurally unrelated to the natural occurring steroid hormones, were sufficiently estrogenic and free from toxicity to warrant their clinical use. These compounds had the advantage of being effective when administered orally. Since 1938, when Dodds, Lawson, and Noble1 reported the high estrogenic activity of diethylstilbestrol, many reports of its use have appeared in the literature. A recent review by MorrelP and the report of the Council on Pharmacy and Chemistry" would seem to make an extensin' reference to thiR literature unnee!'ssary here. Although permanent damage has n£•ver been established on the basis of blood, urine and liver function tests, the incidence of untoward side reactions following the administration of diethylstilbestrol cannot be completely ignot·ed. I wish to report my results ·with a new synthetic estrog·en, not a derivative of stilbestrol, with which J have done extensive clinical work. The compound has the trade name Oetofollin,<~< and is a 2,4-di(parahydroxyphenyl)-3-ethyl hexane. I1 has the following chemical configuration. CH-CII
CH
t ~II"
CH,
CH"
CH,
CH,,
1
i
It might be mentioned here that it is impossible to write this chemical
formula in any way to resemble the natural estrogen, as could be done with diethylstilbestrol. Clinical results upon a selected group of menopause patients treated with this substance, then called 118 B, have been reported by F'reed, Eisin, and Greenhill.), 5 The chemical researches leading to the development of this estrogen and the physiologic work demonstrating its efficacy and safety have been reported.e-s *Product of the Research Laboratories ot Schiet'felin & Co., New York.