Question: Can steroid myopathy weaken the oesophageal opening in the diaphragm and lead to hiatus hernia formation

Dear Dr XXXXXXX

Many thanks for your reply, in answer to my wife's question. I am the patient, now aged 68. I am a retired ophthalmic surgeon practicing in Britain for the last 35 years. I passed my MB, BS, DOMS, MS(Ophth.) in Mumbai (then, Bombay), came to UK and passed DO(Lond.), visited Australia and passed the FRACS, back to UK, awarded the FRCOphth., marriage to my wife Pervin in 1979, have two children, a son XXXXXXX (now, Asst. Prof. in Philosophy & the Humanities, Wesleyan Univ., XXXXXXX ) and a daughter XXXXXXX a Solicitor with a large firm in London. I have suffered from asthma (inherited from my father) since age 30. Later, diagnosed as COPD. Began treatment with bronchodilating inhalers. I have a strong work ethic - my wife never tires of recalling to friends that I went to work for clinic already booked on our marriage day! My wife and I used to work together - often 14 hours per day - doing general ophthalmology esp. in glaucoma where I excelled and working with optometrist colleagues to provide a general ophthalmic service for NHS patients. From 2002 onwards (at age 59), my special interest was oculoplastic surgery. Oddly enough, my work for eye camps in and around Mumbai served me well because much work involved correcting ectropion and entropion, common complications of trachoma - almost endemic in village patients. Corrective surgery for ectropion closely resembles lower eyelid surgery to correct "bags under the eyelids" - given the acronym BUE by me! In this respect, I was well ahead of the "competition" in Britain, having had surgical experience in over 500 patients before I even thought of oculoplastic surgery! My technique was followed by students who came for courses conducted in my XXXXXXX St. clinic. The crash came in XXXXXXX 2006 when an operation for hallux valgus, Left foot, went badly wrong. At that time, my only health problem was asthma/COPD - well controlled with Prednisolone 10 mg per day and nebulization each morning with Salbutamol 5 mg. + Budesonide 1 mg. Also, I had steroid myopathy. To ward off osteoporosis, I took (and still take) Calcium-Magnesium supplements and biphosphonate protection with I.V. Ibandronate three-monthly. The podiatric surgeon made the mistake of attempting an Akin/"scarf" procedure by doing 1st. metatarsal osteotomy with metallic fixation in the presence of an infected 2nd. digit. He amputated the 2nd digit but the damage had been done, made worse by my suppressed immune system. At the first post-op. examination, the wound was open and discharging+. Heavy antibiotics, Flucloxacillin and Penicillin V, with me confined to bed, foot elevated above chest level for 4 months. By November 2006, the foot had "healed" but severely deformed, the 3rd toe taking the place of the 2nd. (amputated) toe and curling under the big toe. I constantly felt as if I was walking on the tip of the third toe! This, with transfer metatarsalgia, increased the pain. [Recently, further complications of undisplaced fracture 3rd metatarsal, formation of a recalcitrant ulcer where the top of the 3rd digit rubs against the bottom of the big toe and recurrent callus formation, sole of the foot.] In January 2007, I was admitted to hospital and told that a small hiatus hernia which was previously asymptomatic, had become a sliding hiatus hernia entering the chest cavity and pressing on the heart. ECG showed bifascicular block and Right bundle branch block. Two questions arose but were never answered: (a) Had the steroid myopathy and immobilization in bed encouraged sliding hiatus hernia? and (b) Was any pressure on the heart causing the ECG changes? In Sept. 2006, "Parkinsonism" was diagnosed and I'm now on Ropinerole 3 mg + co-careldopa t.i.d. My ophthalmic practice ended and I suffered attacks of severe (central) abdomino/vertebral pain with spasmodic "caving" in of the anterior subcostal muscle wall. The hiatus hernia was successfully corrected with fundoplication but the abdominal pain remained unchanged, increasing on forward flexion (e.g. typing this email) and abolished by reclining prone in bed and stretching my spine to its maximum - but only if I take strong pain-killers. I am presently on Oral (liquid) Morphine 15 mg q.i.d., Pregabalin 300 mg b.d., Tramadol 100 mg. t.i.d., Paracetamol 1 G. t.i.d. and Fentanyl patch 25 mcg per hour changed every 3 days. Nitrazepam 5 mg has an almost magical sleep-inducing effect at bedtime. All G.I. tests, CAT scan of abdomen was done - everything normal. Recurrence of hiatus hernia ruled out. MRI of spine turned up chronic disc degeneration, esp. cervical and lumbar levels, scoliosis concavity to left and Grade I spondylolisthesis at L2, L3, L4. At one time, the pain was so great that Inj. Tramadol 100 was prescribed. That was too much - in XXXXXXX 2010, I suffered two back/back respiratory-cardiac arrests. Urgent CPR revived me, I was looked after in the ICU for 2 weeks, further 1 mth in wards, analgesic regime rationalized and discharged. Since then, ECG has stabilised at the same old reading of bifascicular block and Right bundle branch block. No ectopics or arrhythmia. I sleep well, bowel movements OK with enema. Urine normal. Biochemistry normal. B.P. normal. The real incapacitating and debilitating problem is that on waking up and taking weight on the feet (I can nebulize best on standing up), I am seized by pain in the Left foot and a violent subcostal cramp of the abdominal wall which is of demonic intensity. Only relief is taking all pain-killers, completing nebulization as best I can and returning to the prone position stretched out. I spend much of the day like this. Life does not seem to be worth living. The consultant in the Pain Clinic is considering Spinal Cord Stimulation. Your advice would be greatly appreciated. Thanking you,

Respectfully yours,
Daryush A. Irani MS, DO, FRACS

Dear Dr XXXXXXX

I will most certainly take your advice regarding COPD (your para. 1) and heart block (your para. 3).

Regarding 5 ("Most important aspect at present"), the high doses of analgesics are taken not only for the pain after failed surgery on the foot but also for the subcostal cramp which "takes over" from the foot. The subcostal cramp, in turn, gets referred upwards to become a severe and extremely debilitating retrosternal cramp. I get this cramp, as of this moment, while I am typing and it affects every aspect of day to day existence. If I get up and walk around, I stagger about and my knees give way under me. If I talk at the phone, the expiratory effort gives my inunciation a "halting-voice" effect. If I continue typing, the retrosternal cramp takes on a "burning" effect and travels inferiorly to centre on the stomach where it becomes a grinding/crushing pain. If I recline in the prone position, spine stretched to its maximum, the pain subsides within 15 mins but the minute I sit up in bed, it recurs - both as subcostal and retrosternal cramp. Believe me, I was admitted for one month (29th XXXXXXX - 28th July 2009) at the Northwick Park Hospital (a centre of excellence for G.I. conditions) under the consultant gastric surgeon Mr XXXXXXX Gould. Every possible test done: barium swallow turned up mild oesophageal dysfunction which is why I stopped Fosamax and started I.V. Ibandronate 3 mg I.V. three-monthly. The fundoplication seemed to have been successsfully carried out but there is slight paraoesophageal upward herniation which was not regarded as significant. A mass was detected in the right abdominal wall, initially suspected "sarcoma" - subjected to detailed MRI scanning and decided it was benign. Would you recommend further examination of this mass?
MOST IMPORTANT was your comment that the cramping was a complication of fundoplication - stretching of fundus or cardia by sutures or adhesions. Is there a surgical remedy for this? The pain is truly very debilitating.

Thank you very much indeed.

Sincerely and with best wishes,

Daryush A. Irani