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DYSPHAGIA                                        225

seen then no immediate action need be taken, except in one circumstance. If
the patient has ever complained of food sticking during swallowing he should
have an oesophagoscopy because this is one of the earliest signs of cancer.

A chest radiograph should also be done in every case to rule out abnorm-
alities that could cause extrinsic pressure, such as aneurysms. When the patient
has inhalational problems signs are seen on the chest radiograph that may
resemble cannonball secondaries. While these may well represent metastases,
they may also denote patches of consolidation due to food debris and infection.
4. Oesopfaagoscopy. This is done with either a rigid tube or a flexible oesophago-
scope. The technique is described in Chapter 41 (p. 212).

Hiatus Hernia.


1.  Congenitally short oesophagus with thoracic stomach. This accounts for
5 per cent of cases. The stomach is not truly herniated, since it has never been
below the diaphragm.

2.  Oesophageal hiatus hernia with shortened oesophagus. This is acquired
rather than congenital and the oesophagus becomes shortened as a result of
tonic contractions or cicatricial shrinkage.

3. Oesophageal hiatus hernia without shortening of the oesophagus OSliding
hernia')- This type together with the hernia with a short oesophagus forms
87 per cent of hiatus hernias. The cardia is incompetent, as is the diaphrag-
matic valve.

4. Para-oesophageal hernia through the hiatus. This forms 6 per cent of cases.
A portion of the stomach herniates through the oesophageal hiatus and comes
to lie alongside, and parallel to, the lower end of the oesophagus. An impor-
tant feature is that the oesophagogastric junction lies below the diaphragm.

AETIOLOGY. Most patients are obese and the male : female ratio is I : 2. It is
most commonly seen over the age of 40 and its greatest frequency is between
60 and 80 years.

SYMPTOMS. No definite symptoms are pathognomonic and in some cases the
patient is asymptomatic. In the symptomatic cases the main complaints are of
epigastric discomfort, postural heartburn, flatulence, dysphagia and a
feeling of a lump in the throat.

TREATMENT. The most important point in treatment is to get the patient to
lose weight, sleep upright, avoid constrictive clothing and to eat small meals
often. Antispasmodics and mild sedatives are useful, as is Mucaine which acts
as a protective to the inflamed oesophagus. 5-10 ml are taken four times daily
before meals and at bedtime. If heartburn forms a major part of the picture
then it should be treated with 10 ml of aluminium hydroxide gel (Aludrox)
every 2 hours. If conservative treatment fails attempts should be made to
reduce the hernia surgically and to repair the diaphragmatic sphincter.


AETIOLOGY. The commonest causes of this are: (1) Long-standing oesophag-
itis; (2) Surgical correction of hiatus hernia or of a previous stricture; (3)
Corrosive oesophagitis; (4) Cancer of the oesophagus.