“Tony, come take a look.” Forrest beckoned me into the endoscopy suite. The patient, well sedated, lay with the thin black endoscopy tube still down his throat. On the overhead screen, the far end of the pink esophagus ballooned into dark stomach folds.
“Wow. That’s big, isn’t it?” I asked.
“Huge,” came the answer.
“His wife says he gets short of breath when he flies. Any connection?”
He gave me a look, as if I’d just asked who was buried in Grant’s tomb.
“People with big hiatal hernias have lots of trouble on planes,” he explained patiently. “When you’re sitting at a 90-degree angle for hours, everything gets pushed up.”
I headed out of the room to explain the diagnosis to the patient’s wife.
“So you’re sure it’s not his heart?”
“Yes. Best of all, it explains the plane trouble too.”
Josie was at the patient’s bed, fussing with the monitors. She winked, as if to say, I told you, not cardiac.
Hiatal hernias are extremely common. In some emergency departments where I’ve worked, it seems everyone over 50 with good health insurance (meaning access to a gastroenterologist and an endoscope) carries the diagnosis. Medical studies report that about 20 percent of older Americans live with part of their stomach where it doesn’t belong, which, among other things, can greatly confound the assessment of chest pain.
I witnessed this firsthand when another patient came in a few weeks after the banker. She was in her mid-forties, curled up on a gurney, wailing in Spanish that she couldn’t stand the pain. “Vomiting and vomiting. Nothing stays down. For weeks. My head. Oh my God, it is a pain that wants to kill me.”
Brain tumor? I wondered.
“Vomiting for two weeks,” Susan, my resident, told me.
“That’s a long time,” I replied. “She’s either very sick or very pregnant.”
I turned to the patient. “Can you tell me where it hurts?”
“Oh, my head!”
“What time of day do you vomit?” (Brain tumors hurt more after a night’s sleep because pressure in the brain increases while the patient is lying down.)
“All the time! I can’t keep food down.”
“Ever have hepatitis?”
“They operated on my tubes.”
“They took it out. Years ago.”
“Oh, I hurt everywhere.”
The patient’s neurological exam was normal. Her belly was tender all over. She wasn’t jaundiced. Stumped, I turned to Susan. “It would be nice to know which organ system is malfunctioning.”
I stared at the patient, thinking, Pick an organ, any organ. “Let’s scope her,” I finally said. “Check for tumors blocking stomach emptying. Or scarred-down ulcers. In the meantime, how about some intravenous fluids and an antiemetic?”
Her endoscopy looked just like what I’d seen in the man with the puzzling chest pain. I explained to her what we’d found.
“You mean all my pain and vomiting and headaches,” she said, “it’s from my stomach pushing up?”
“The symptoms of hiatal hernia and acid reflux are often severe. The chest pain can squeeze like a heart attack; the lungs can wheeze when acid backs up through the esophagus into them, often during sleep. You can experience vomiting, choking, even pneumonia.”
“From the stomach?” she interrupted, still incredulous.
“I’m afraid so. For a relatively benign condition, it can cause an astonishing amount of aggravation.” Then I told her what I had told the couple: “The solution is to eat small meals and take the acid-suppressing pills I will prescribe for you.”
I didn’t tell her that surgical procedures, called fundoplications, can reinforce the sphincter between the esophagus and the stomach, reducing acid reflux. That bridge did not need to be crossed for a while.
A week later, the patient who’d come in because of chest pain showed up in the emergency room. He was carrying chocolates and a bouquet but bustled right past me.
“How nice,” I thought, “one clever diagnosis, another grateful patient. I wonder what he brought me.”
A few minutes later, waving farewell, he called out, “You have a great staff.”
I walked into a side room and found Josie admiring her flowers and bonbons.
“What a nice patient,” she said.
“Yes,” I said, a tiny bit deflated. “I guess he knows talent when he sees it.”
Tony Dajer, a frequent contributor to Vital Signs, is the assistant director of the emergency medicine department at New York University Downtown Hospital in Manhattan. The cases described in Vital Signs are true stories, but the authors have changed some details about the patients to protect their privacy.