What happened, in summary

An 85-year-old woman developed 2 months of poor appetite, heartburn and vomiting after eating, followed by persistent nausea, malaise and difficulty swallowing. CT showed an “upside-down stomach,” with the entire stomach herniated into the chest, and marked thickening of the stomach wall. Endoscopy was technically difficult because of the distorted anatomy and did not initially identify an obvious cancer. Hernia repair was therefore planned.

During surgery, the stomach felt diffusely hardened. Fluid in the abdomen was found to contain poorly differentiated adenocarcinoma cells, and examination suggested that the gastric process extended through the stomach toward about 4 cm of the lower esophagus. The findings led to a diagnosis of extensive scirrhous gastric cancer.

Because of her age and the risks of a much larger operation, the team did not attempt gastrectomy or esophagojejunal reconstruction. The operation was limited to repairing the esophageal hiatus and returning the stomach to the abdomen. Her severe nausea and malaise improved after surgery, but passage through the lower esophageal region remained markedly delayed and eating was still difficult. A central venous port was placed on postoperative day 18, and she was transferred to another medical hospital on day 52.

Her case shows how severe anatomic distortion from a large hiatal hernia can mask the symptoms and endoscopic appearance of an extensive gastric cancer.