Thomas Scherer, D.O. writes about one of the disorders of the digestive tract: hiatal hernia [“High-A-tul Her-knee-uh”]. This article was published in The Central Oregonian in August 2007.
Our digestive tract is a complex system of organs that convert the food we eat into the nutrients we need to live. We would expect a system as well-used as the digestive tract to be the source of many problems, and it is. Diseases of the digestive tract are responsible for the hospitalization of more people in the United States than any other group of disorders.
In my practice, I am often asked questions about hiatal hernias by my patients and their families. As a General Surgeon for over 15 years, I have to say, I have seen between 1,000 and 2,000 cases.
First, what is a hiatal hernia? Any time an internal body part pushes into an area where it doesn’t belong, it is called a hernia. The hiatus is an opening in our diphragm – the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus—food pipe – goes through the hiatus and attaches to the stomach. In a hiatal hernia, the stomach bulges up into the chest through that opening.
There are two main types of hiatal hernias: sliding and paraesophageal—next to the esophagus. In a sliding hiatial hernia, the stomach and the esophagus slide up into the chest through the hiatus. This is the more common type of hernia.
The paraesophageal hernia is less common, but is more cause for concern. The esophagus and stomach stay in their normal locations, but part of the stomach squeezes through the hiatus, placing it next to the esophagus. Although you can have this type of hernia without any symptoms, the danger is that the stomach can become ‘strangled’ or have its blood supply shut off.
Often, people with hiatal hernia also have heartburn or gastroesophageal reflux disease (GERD). Hiatal hernia strongly contributes to GERD, but does not have to be present to have GERD. GERD is an extremely common problem, and exists in 25% to 33% of the population at some time during their lives. Frequent GERD (more than two times a week) needs to be addressed by a physician as it is associated with an increasing incidence of Barrot’s esophagus (abnormal cells), dysplasia (pre-cancerous cells) and esophageal adenocarcinoma. Dr. Para Chandrasoma at the University of Southern California Keck School of Medicine’s pathology department feels that the self-medicating population of GERD patients “are the iceberg under the tip” of patients who will result in an explosion of esophageal adenocarcinoma cases.
In addition, people with a hiatal hernia may experience chest pain that can easily be confused with the pain of a heart attack. It is important to undergo testing and get properly diagnosed.
What causes a hiatal hernia? Most of the time, the cause is not known. Some people develop a hiatal hernia following an injury to that area of the body; others are born with a weakness or an especially large hiatus. Some experts suspect that increased pressure in the abdomen from coughing, straining during bowel movements, pregnancy and delivery or substantial weight gain may contribute to their development.
Who is at risk for hiatal hernia? More often, I see them in people over the age of 50 and in overweight people, especially women, and in smokers. I have seen them in many people from 20 to 40 years, and occasionally in teens.
How is a hiatal hernia diagnosed? With a barium study—a special X-ray or CT scan that allows me to see your the esophagus and with endoscopy. Only endoscopy can detect abnormal cells or damage.
How are hiatal hernias treated? Many people do not experience any symptoms of their hiatal hernia, so no treatment is necessary in those cases. However, the paraesophageal hernia can cause the stomach to be strangled, so surgery is usually recommended. Other symptoms that may occur along with the hernia, such as chest pain, should be properly evaluated. Symptoms of GERD should be treated, usually first with proton pump inhibitors under a doctor’s supervision.
When is surgery necessary? Rarely, if your hiatal hernia is in danger of becoming constricted or strangulated so that blood supply is cut off, surgery may be needed to reduce the hernia, put it back where it belongs. More commonly, GERD may be treated with medicine or surgery under a doctor’s supervision.
Hiatal hernia surgery can be performed with a laparoscope, which we have available at Pioneer Memorial Hospital , and which I have special expertise in. During the surgery, five small (5 to 10 mm) incisions are made in the abdomen. The laparoscope and surgical instruments are inserted through these incisions. I am guided by the laparoscope, which transmits a picture of the internal organs to a monitor. The advantages of laparoscopic surgery include smaller incisions, less risk of infection, less pain and scarring, and a more rapid recovery.
Most of my patients are able to walk around the day after hernia surgery. Generally, the patient needs to take a soft diet and avoid carbonated beverages for a couple of weeks after surgery. My patient can resume his or her regular activities within a week or two. Complete recovery will take four to six weeks, and you should avoid hard labor and heavy lifting for two weeks after surgery.
When should you call the doctor? If you have been diagnosed with a hernia, and you have the following symptoms – nausea, vomiting, unable to have a bowel movement, or pass gas—you may have a strangulated hernia or an obstruction. These are medical emergencies. Call your doctor immediately.
Thomas Scherer, D.O., is a general surgeon who has his offices in the Physician Associates Medical Building; 1251 NE Elm Street; Prineville, OR. Phone number for appointments is 541-447-1008. Or on the web, visit www.doctorscherer.com.