Introduction

Abstract

Dorothy Smith, an elderly and somewhat portly woman, presented to her local emergency department with chest pain and shortness of breath. An extensive evaluation revealed no evidence for coronary artery disease, congestive heart failure, or pneumonia. A chest radiograph demonstrated a large air-fluid level posterior to her heart shadow, a finding that all thoracic and general surgeons recognize as being consistent with a large paraesophageal hiatal hernia. The patient had not had similar symptoms previously. Her discomfort was relieved after a large eructation, and she was discharged from the emergency room a few hours later. She was seen several weeks later in an outpatient setting by an experienced surgeon, who reviewed her history and the data from her emergency room visit. After evaluating a CT scan and barium swallow, the surgeon diagnosed a giant Type III paraesophageal hernia. The patient was told that an operation is often necessary to repair such hernias. Her surgeon indicated that the objectives of such an intervention would include relief of symptoms such as chest pain, shortness of breath, and postprandial fullness, and prevention of catastrophic complications of giant paraesophageal hernia, including incarceration, strangulation, and perforation. Ms. Smith, having recovered completely from her episode of a few weeks earlier, declined intervention, despite her surgeon’s strong expression of concern.