Stomach Protrusion

A Hiatus Hernia means that part of the stomach protrudes through the hiatus (or opening) that occurs in the diaphragm (the large muscle dividing the thoracic cavity from the abdominal cavity). The point of significance is that when this takes place, it is invariably associated with a condition called “reflux.” The cardiac valve (that closes the lower end of the esophagus off from the stomach) tends to weaken, and acid contents of the stomach tend also to regurgitate or reflux into the lower end of the gullet. This tends to produce burning and irritation. So, a burning sensation, heartburn, and general discomfort often felt behind the breastbone (sternum) all occur.

Sometimes the hernia slides back and forth, the valve opens and closes irregularly, so symptoms come and go also. Sometimes these are associated with a history of an accident (such as a violent motor-vehicle mishap), but often there is no obvious cause for this condition.

Symptoms

General discomfort at the lower end of the breastbone (in the epigastric region) may occur either intermittently or more continuously. This may either be a painful or a burning sensation, or both. Often this is worse when the person is stooping or lying, particularly on the right hand side.

Symptoms are aggravated by eating spicy food, hot sauces, condiments, the overuse of pepper, alcohol, strong tea and coffee and, of course, cigarette smoking (acids from the smoke dissolve in the saliva, are swallowed, and act as a powerful gastric irritant). Sometimes in severe and long-standing cases, the inflamed end of the esophagus may bleed, or constriction might occur as nature tries to repair the inflamed area.

Symptoms may come and go in a mysterious manner. Strange to say, as soon as a diagnosis has been made, many people begin to develop symptoms for the first time. Many cases are diagnosed quite by chance during an X-ray or endoscopic examination for something quite different!

Treatment

General medical treatment is often quite satisfactory, and most of this can be carried out on a do it yourself basis once the diagnosis has been confirmed. Frequently therapy is needed only if and when symptoms occur. Keeping the stomach where it belongs can be assisted by raising the head of the bed fifteen to twenty-five centimeters. This is often unpopular as the patient (and partner) tends to slip down toward the bottom of the bed during the night, and this may breed matrimonial dissent!

The avoidance of bending forward (i.e. bending at the middle) is advisable, for this may initiate symptoms during quiescent times. Rather, bend the knees to lower the body, this may be important when picking up parcels, or if the patient is an enthusiastic gardener.

The sensible use (not overuse) of antacid products will often bring prompt relief from the burning sensation by temporarily neutralizing the acid in the lower gullet. Any of the many products readily available will assist. Often liquids may give the quickest response, for they do not take time to dissolve. Those containing a local anesthetic may act even more effectively. When taken orally, alginic acid compound often confers substantial relief also.

Weight reduction is considered to be very important. A large abdomen tends to press inwards and upwards, so forcing more acid into the esophagus, and weakening the cardiac valve still further. Chocolate, coffee and fatty foods reduce the efficiency of the cardiac valve, tend to increase reflux and heartburn, and should be avoided. It is also advisable for the patient to avoid a large meal for at least three hours prior to bedtime.

Medication

Drug medication allows great improvement and a major reduction in symptoms. The family of drugs, “Histamine H 2-Receptor Antagonists”, Cimetidine (Tagamet), Ranitidine (Zantac) and Famotidine (Pepcidine) have a dramatic effect in reducing acid production by the walls of the stomach. They cause a rapid reduction in symptoms, and allow healing in a short space of time. Symptoms often vanish within eight weeks. Unfortunately, many patients relapse after this if they discontinue medication. A smaller maintenance dose may be required for a long time (similar to the treatment of ulcers). Misoprostol, a synthetic prostaglandin, is claimed to be as effective. It is taken for four weeks, three times a day, but often causes diarrhea.

Probably the best and most recent medications are Omeprazole (Losec) and Lansoprazole (Zoton), and so-called “Protonpump Inhibitors.” In short, they help stop acid being pumped from glands in the stomach wall into the stomach itself. Other “look alike” medications will inevitably be developed, and are prescribed for specific cases under medical supervision.

Another drug called Sucralfate (Carafate) is claimed to be cytoprotective, in that it covers the ulcers with a healing material. It is often used if other medications fail. Other products continually become noticed as they are invented.

Surgical Correction

If simple measures do not cure the patient, it is possible to resort to surgical correction. Many methods have been tried over the years. A device called the Angel chick prosthesis helped some. This is where a horseshoe shaped plastic device is placed around the lower end of the esophagus below the diaphragm, anchoring the stomach in the abdominal cavity. This is supposed to prevent it from sliding.

Hiatus Hernia/ Keyhole Surgery

Patients with severe symptoms from hiatus hernia may now undergo laparoscopic surgery. Through tiny one cm incisions in the abdomen (called “portals”), instruments, lights and a camera are inserted into the abdominal cavity. The hernia is gently retracted and securely anchored in the abdominal cavity, thus preventing it from sliding upwards in the future.

The operation takes several hours, but the patient is often up the next day and home within three to five days and may be back to work in seven to fourteen days. Symptoms usually vanish, normal eating habits are restored, and the patient feels much better. Major capital city hospitals are now geared with the equipment, and the small number of surgeons capable of performing this operation is gradually increasing. It is a major step forward, and further improvements in technology are inevitable.

Another surgical measure is termed the Nissen fundoplication operation which reshapes the lower end of the esophagus, reducing reflux and herniation. In the hands of a skilled surgeon this too is successful. However, with the advent of the laparoscope and keyhole surgery, excellent results are now achieved. The stomach and sliding portion are securely anchored in the abdominal cavity with minimum trauma to the patient. Results are good.