Can steroid myopathy weaken the esophageal opening in the diaphragm and lead to hiatus hernia?

Posted on Fri, 15 Jun 2012 in General Health
Question: Can steroid myopathy weaken the oesophageal opening in the diaphragm and lead to hiatus hernia formation
Answered by Dr. Gyanshankar Mishra 1 hour later

Thanks for the query.

Steroid myopathy of the diaphragm leading to hiatus hernia has so far not been reported in literature. Also steroid myopathy spares the sphincters.

However for hypothesizing steroid myopathy of the diaphragm to be etiological factor of hiatus hernia, clinical features of diaphragm weakness have to be demonstrated prior to development of hiatus hernia.

The clinical features of diaphragm weaknes are : complaint of dyspnea(breathlessness) (particularly on exertion) or orthopnea 9breathlessness on lying down position); the presence of rapid, shallow breathing or, more importantly, paradoxical inward motion of the abdomen during inspiration on physical examination; a restrictive pattern on lung function testing; an elevated hemidiaphragm on chest radiograph; paradoxical upward movement of 1 hemidiaphragm during fluoroscopic imaging; or reductions in maximal static inspiratory pressure. The diagnosis of diaphragmatic weakness is confirmed, however, by a reduction in maximal static transdiaphragmatic pressure (Pdimax).

Thus it is very unlikely in absence of features of diaphragm weakness, that steroid induced myopathy of the diaphragm leads to hiatus hernia.

Hope I have answered your query. Please accept my answer in case there are no further queries.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Gyanshankar Mishra 3 hours later

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
Answered by Dr. Gyanshankar Mishra 1 hour later
Dear Dr. Irani,
Thanks for the follow up.
Its indeed pleasure for me to be introduced to a dedicated doctor of your caliber who has accomplished so much in life.
Your narration of your medical history is really detailed and very helpful.
I will attempt to address your query at this stage.
Your diagnosis currently includes the following:
1. Obstructive Airway Diseases (may be overlap syndrome of asthma/copd) - you are currently taking your inhalers. Do get your pulmonary function tests done and optimise your treatment according to the clinical features in correlation with your pulmonary functions. Also do get yourself vaccinated by annual influenza vaccine and 5 yearly pneumococcal vaccine to reduce the chances of respiratory infections in near future considering your co morbidities.It would be best to visit a Pulmonologist for that.
2. Parkinsonism: on Ropinerole 3 mg + co-careldopa t.i.d.
3. Previous h/o heart block: suffered an attack of cardiac arrest in the past: since no medicines are given in the history, i presume you are not taking any. I suggest that you get a detailed cardiac evaluation by a cardiologist for the same since it can be really XXXXXXX at times. Detailed cardiac evaluation includes -ECG/ 2D ECHO/24 hour Holter monitoring/ Cardiac angiography to see the anatomic condition of your coronaries/ Serum triglyceride levels.
4. Chronic disc degeneration (On MRI): seems to be probably age related.
5. Most important aspect at present:
- pain in the left foot (post operative): you need to take analgesics. However other options like spinal cor stimulation as planned by your anasthetis need to be looked for as you cannot take long term analgesics which might hamper your renal functions.
- Subcostal cramp: This seems to be an after effect of fundoplication, generally seen in about 12 % of cases post operatively due to stretching of fundus or cardia by sutures or adhesions (As it typically changes with posture). This requires analgesics/ spasmolytics /antacid for the management. Again other options as advised by your anaesthetist should be tried.
Believe me anaesthetists are best at pain management. You can also inquire about intradermal patches for pain relief.

The main hindering factors seem to be the presence of all these co morbidities at your age.

The illustrious life that you have lived till date is testimony to the fact that you are a very strong person and will face life with all its sweet and sour experiences.You should not be disheartened at all and look at a step wise approach to all these comorbidities.

I have tried to address your queries in this forum.
Please accept the answer if there are no further queries. I will be glad to answer follow up queries if any.

Wish you good health.
Take care.

Dr. Gyanshankar Mishra
Above answer was peer-reviewed by : Dr. Raju A.T
Follow up: Dr. Gyanshankar Mishra 16 hours later

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

Answered by Dr. Gyanshankar Mishra 2 hours later

Dear Dr. Irani,

Thanks for your response.

My impression regarding the issues presented by you are as follows:

1. The abdominal wall mass:
The radiologist is usually confident when he/she makes a radiological diagnosis of a benign mass. Here there are 2 options - radiological follow up of the mass for minimum of 2 years or Ultrasound / CT guided FNAC of the mass to confirm its benign nature.

2. Pain in the abdomen:
- In addition to the factor mentioned above, I would also like to point out that post nissen fundoplication , you are sometimes not able to burp (Please take a note of - whether you burp or not?). There is a high incidence of gas accumulation in the abdomen (post fundoplication gas bloating syndrome) that lead to the type of pain (changes the site and intensity with posture) that you mentioned.

Regarding this pain, you may try the following:
a. Do not eat heavy meals.
b. Do not eat gas forming foods like beans/ pulses/ etc.
c. Drug formulation with simethicone might help.
d. If analgesics and conservative measures (Aid from anaesthetists regarding pain management) do not relieve this pain then you can consider a ‘take down’ of fundoplication. This issue can be discussed with your surgeon.

In short the indication of take down fundoplication is as follows:
"Revisional surgery (redo fundoplication) is offered to patients who have persistent, recurrent, or new foregut symptoms (heartburn, dysphagia, chest pain, regurgitation, asthma, hoarseness, chronic cough, or laryngitis) and confirmed physiologic abnormalities (mild esophageal dysfunction in your case) or a definable anatomic defect (slight paraoesophageal upward herniation in your case).”

The surgeon's call should be the final on this.

I have tried to address the issues here. Hope your query has been answered. Please accept my answer if there are no follow up queries.


Dr. Gyanshankar Mishra

Above answer was peer-reviewed by : Dr. Prasad
Answered by
Dr. Gyanshankar Mishra


Practicing since :2003

Answered : 600 Questions


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