A 54-Year-Old Man Comes to the Office Due to Several

A 54-year-old man comes to the office due to several months of heartburn, acid regurgitation, and dysphagia.  He has taken antacids and over-the-counter medications without relief.  Medical history includes hypertension and hyperlipidemia.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  BMI is 32 kg/m².  Physical examination is unremarkable.  Upright chest x-ray shows an opacity with an air-fluid level behind the heart.  A subsequent barium swallow reveals the proximal stomach herniating through the esophageal hiatus.  Which of the following pathophysiological changes most likely contributed to this patient's current condition?

A) Cephalad migration of the squamocolumnar junction with a fixed gastroesophageal junction
B) Circumferential laxity of the phrenoesophageal membrane
C) Diaphragmatic muscle paralysis due to C3-5 motor nerve injury
D) Failure of the posterolateral diaphragmatic foramina to fuse
E) Herniation of abdominal contents through the omental foramen

Correct Answer:

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