Hiatus hernia

Description

A hiatus hernia occurs when the upper part of the stomach, which is joined to the oesophagus (gullet), moves up into the chest through the hole (called a hiatus) in the diaphragm. This is a common occurrence in about 10 per cent of people.

A hiatus hernia usually does not cause symptoms or problems. However, when it does, the physician can frequently treat the problem effectively with a well-planned programme.

Gastro-oesophageal refers to the stomach and oesophagus. Reflux means to flow back or return. Therefore, gastro-oesophageal reflux is the return of the stomach's contents back up into the oesophagus. Gastro-oesophageal reflux disease (GORD) is a digestive disorder that affects the lower oesophageal sphincter (LES) - the muscle connecting the oesophagus with the stomach.

Doctors believe that some people suffer from GORD due to the condition of hiatus hernia.

In normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the oesophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately allowing the stomach's contents to flow up into the oesophagus.

The severity of GORD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva. Many people, including pregnant women, suffer from heartburn or acid indigestion caused by GORD but not necessary a haitus hernia. In most cases, heartburn can be relieved through diet and lifestyle changes; however, some people may require medication or surgery.

Some doctors believe a hiatus hernia may weaken the LES and cause reflux. Recent studies show that the opening in the diaphragm acts as an additional sphincter around the lower end of the oesophagus. Studies also show that hiatus hernia results in retention of acid and other contents above this opening. These substances can thus reflux easily into the oesophagus as a part of the stomach is above the diaphragm.

Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatus hernia in susceptible subjects. Obesity and pregnancy also contribute to this condition. Many healthy people age 50 and over have a small hiatus hernia without symptoms. Although considered a condition of middle age, hiatus hernias affect people of all ages.

Hiatus hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply, i.e., paraesophageal hernia) or is complicated by severe GORD or oesophagitis (inflammation of the oesophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

Cause
 

Any condition that contributes to the weakening of the LES may cause reflux and heartburn. Dietary and lifestyle choices may contribute to GORD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee, or alcoholic beverages, may weaken the LES causing reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also relax the LES leading to GORD.

Symptoms
 

Heartburn, also called acid indigestion or dyspepsia, is the most common symptom of GORD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many persons say it feels like food being passed back into the mouth leaving an acid or bitter taste.

The burning, pressure, or pain of heartburn can last as long as two hours and is often worse after eating. Lying down or bending over can also result in heartburn. Many persons obtain relief by standing upright or by taking an antacid that clears acid out of the oesophagus.

Heartburn pain can be mistaken for the pain associated with heart disease or a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity.

Prevalence
 

Hiatus hernias are very common, occurring in up to 60 percent of people by age 60. Twenty-five percent of pregnant women experience daily heartburn, and more than 50 percent have occasional distress. A high percentage of the South African population experience heartburn partly due to the lifestyle and dietary choices.

Recent studies show that GORD in infants and children is more common than previously recognized and may produce recurrent vomiting, coughing and other respiratory problems, or failure to thrive.

Course
 

At times GORD results in serious complications. Oesophagitis can occur as a result of too much stomach acid in the oesophagus. Oesophagitis may cause oesophageal bleeding or ulcers. Anaemia due to chronic bleeding from the lower oesophagus may occur. While sleeping, stomach secretions may seep up the oesophagus and into the lungs causing chronic cough, wheezing, and even pneumonia. In addition, a narrowing or stricture of the oesophagus may occur from chronic scarring. Some people develop a condition known as Barrett's oesophagus, which is severe damage to the skin-like lining of the oesophagus. Doctors believe this condition may be a precursor to oesophageal cancer.

Diagnosis

• An upper GI barium x-ray may be performed during the early phase of testing. This test is a special x-ray that shows the oesophagus, stomach, and duodenum (the upper part of the small intestine). While an upper GI series provides limited information about possible reflux, it is used to rule out other diagnoses, such as peptic ulcers.
• Endoscopy is an important procedure for individuals with chronic GORD, in which the physician visually examines the oesophagus and stomach using a flexible scope while the patient is lightly sedated. If the findings of the endoscopy are abnormal or questionable, biopsy (removing a small sample of tissue) from the lining of the oesophagus may be of use.
• Oesophageal manometric studies pressure measurements of the oesophagus - occasionally helps identify critically low pressure in the LES or abnormalities in oesophageal muscle contraction.

For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the oesophagus through pH testing. Testing pH monitors the acidity level of the oesophagus and symptoms during meals, activity, and sleep. Newer techniques of long-term pH monitoring are improving diagnostic capability in this area.

Treatment

• Doctors recommend lifestyle and dietary changes for most people with GORD. Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the oesophagus from refluxed materials.
• Avoiding foods and beverages that can weaken the LES is recommended. These foods include chocolate, peppermint, fatty foods, coffee, and alcoholic beverages. Foods and beverages that can irritate a damaged oesophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided.
• Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least two to three hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight.
• Cigarette smoking weakens the LES. Therefore, stopping smoking is important to reduce GORD symptoms.
• Elevating the head of the bed on 10cm blocks or sleeping on a specially designed wedge pillow reduces heartburn by allowing gravity to minimize reflux of stomach contents into the oesophagus.
• Antacids taken regularly can neutralize acid in the oesophagus and stomach and stop heartburn. Many people find that nonprescription antacids provide temporary or partial relief. Long-term use of antacids, however, can result in side effects, including diarrhoea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease. If antacids are needed for more than three weeks, a doctor should be consulted.
• For chronic reflux and heartburn, the doctor may prescribe medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. Currently, four H2 blockers are available: cimetidine, famotidine, nizatidine, and ranitidine.
• Proton pump inhibitors are today the drugs of choice and first line of medical treatment for recalcitrant reflux oesophagitis (GORD). This could mean life-long medication due to the high relapse-rate after discontinuing medication. Proton pump (or acid pump) inhibitors inhibit an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion.

Other approaches to therapy will increase the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal (GI) tract. These drugs include bethanechol and metoclopramide.

Surgery
 

A small number of people with GORD may need surgery because of severe reflux and poor response to medical treatment. Laparoscopic fundoplication (or keyhole surgery) is a viable option for chronicity and failed medical treatment. Fundoplication is a surgical procedure that increases pressure in the lower oesophagus. Open surgery is now reserved for complex cases. All candidates for fundoplication will need 24-pH monitoring of acid-reflux status and is performed by a gastroenterologist.

Prevention
 

There are several ways in which one can help to prevent and cope with the heartburn of hiatus hernia:

• Avoid late night eating. This will encourage excess acid production during sleep when there is little opportunity to "work off" the meal.
• Eat frequent small meals rather than occasional large ones. This will minimise the stimulus of a single large meal to produce a vast quantity of acid. Frequent small meals will help to "mop up" the excess acid that might already be present in the stomach.
• If obesity is a problem then weight reduction will help minimise the symptoms.
• Avoid tight fitting clothing - so reducing pressure on the abdomen and hence the stomach.
• Elevate the head of the bed by 5 - 10 cm. This will utilise gravity to help minimise acid regurgitation when lying down.
• Do not bend over or lie down horizontally after eating a meal.
• Avoid smoking and excess alcohol consumption. Cigarette smoke and alcohol relax the ring of muscle around the gullet and so enable acid regurgitation to occur. After a meal, when the stomach is full, smoking increases the chances of heartburn occurring.

(Reviewed by Prof Don du Toit)