Published in Panorama
Treating Hiatus Hernia
Baby Abdul has been throwing up nearly after every feed and also a few times between feeds. He was diagnosed as having gastro-esophagul reflux.
Rahul, at 5, is showing up symptoms of asthma and wheezing. An X ray showed mild symptoms of pneumonitis for which he was treated. But the episodes recurred.
Javed at 50 suffers severe bouts of heartburn and occasionally has pain and difficulty while swallowing.
Dr.Qurban Hatim Pamina, General and Laparoscopic Surgeon, Zulekha Hospital, Sharjah, reveals that all these individuals could be having hiatus hernia as the underlying problem.
What is hiatus hernia and why do people get it? Dr.George Emmatty, General Surgeon, Indian Specialist Medical Centre explains, “There are naturally present openings in the diaphragm, the muscular sheet which separates the abdomen from the chest, for the passage of the food pipe (the oesophagus) and the main artery (the aorta). In a hiatus or diaphragmatic hernia, the oesophagal opening becomes large and through this, a part of the stomach comes up into the chest cavity.”
There are several causes of a hiatal hernia which generally happens when there is any undue or increased pressure in pressure in the abdomen, which may be brought on by coughing, straining, heavy lifting and pregnancy. Other risk factors include obesity, intra-abdominal tumour, and weakness of abdominal muscles from aging and previous surgery.
Dr.Qurban opines, “Though it is usually the middle-aged who have this problem, Hiatus hernia may be seen even in infants in whom it manifests as gastro-esophagal reflux and the consequent failure to thrive, anaemia and asthma-like symptoms”.
Hiatus Hernia may be of two types, the sliding hernia or the para oesophagal hernia, explain the doctors. Dr.Qurban elucidates, “The sliding hernia is one in which the gastro-esophageal junction and part of the stomach slides into the chest. This junction can stay permanently in the chest, or just slide into the chest during swallowing. The food pipe is shortened and it goes up into the chest. In the para oesophagal kind, the gastro-esophageal junction remains where it belongs, but part of the stomach is squeezed up into the chest beside the esophagus. In children, particularly infants, most hiatal hernia are of the sliding type.”
What are the symptoms of hiatus hernia? While most of the times patients are asymptotic, that is, they don’t show up any symptoms, there is sometimes vomiting after food, reveals Dr.Emmatty. Only 15% of people with hiatus hernia, really come up with symptoms. The symptoms are almost like those of gastric problems of duodenal ulcer, heartburn, chest discomfort, tightening sensation in the chest especially after food and the stomach feels bloated after eating. There may be some mid chest pain because of the gastric acid from the stomach getting pushed up into the foodpipe. The pain and heartburn may worsen with lying down. In the balance 85% of people with hiatus hernia, they have no symptoms and live with the problem without even being aware of it.
Dr.Qurban adds, “Clinically, nausea and vomiting are uncommon in adults and there is more of heartburn. Nausea and vomiting are more common in children and there is failure to thrive. This is the result of regurgitation of the food by the child since the food cannot be contained in its stomach. The food comes up into the food pipe and chest and then the child vomits. This refluxing food can even come up into the upper end of the food pipe, without coming into the mouth but can enter the air pipe. When this happens, it can cause pulmonary or lung symptoms and the child will present with asthma like symptoms with wheezing, difficulty in breathing. When you take an X Ray, you will find signs of a mild pneumonitis. Seeing this, the physician may treat the child symptomatically for pneumonitis while the real problem causing the condition is a hernia! So if a child is not thriving and appears anaemic, gets recurrent pneumonitis, then you could look for hiatus hernia as a cause.”
How is hiatus hernia diagnosed? There are only two tests involved in diagnosing the condition, says Dr.Emmatty: non-invasive barium meal test and upper gastro-intestinal endoscopy.
Dr.Qurban emphasizes, “If, while doing an endoscopy to diagnose some other condition, you chance upon para oesophagal hernia in a patient who is not showing up any symptoms of the condition whatsoever, you should advise the patient to have it operated. This is because it is so prone to complications!”
In para esophagal hernia, explains Dr.Qurban, complications can occur. For instance, the hernia can get incarcerated or stuck and squeezed and consequently strangulated because there is a lack of blood supply, leading to death of the tissues involved. Sometimes bleeding can occur from erosions within the herniated part of the stomach which may be one factor contributing to the anaemia also; and this can happen in children and adults alike.
What is the treatment of hiatus hernia? While an operative repair of any hernia, sliding or para oesophagal, is the same, only about 15% of the cases require surgery, assures Dr.Emmatty. “t is best to treat and control the underlying conditions. For instance, if the patient is obese, he has to modify his lifestyle, diet and exercise regimen to lose weight. He should eat smaller meals more frequently and avoid foods and beverages that may cause acid reflux symptoms. They should have light food at night and have it at least two hours before bed time. Also, to reduce the amount of acid secretion, patients may be prescribed acid blocks, antacids and drugs which diminish acid secretion. In addition, these individuals should lie down with their heads raised between 6 and 8 inches above the bed, so that the food pipe is at a higher level than the stomach.”
Elaborating on the surgical treatment of hiatus hernia, Dr.Qurban explains, ”While the laparoscopic abdominal approach is the most popular, sometimes, it becomes necessary to do an open procedure by making an incision in the thoracic region and approach the hernia from above the diaphragm. In some cases a combination of the abdominal and thoracic approach are needed.”
What do these surgeries involve? Dr.Qurban explains, “Whenever you have a hernia, the first thing to do is to reduce the contents, that is, whatever organ is in an abnormal position, you have to pull it back to its normal position. After doing this, you have to fix it there. This is followed by reconstruction. While this entire sequence of procedures may be successfully and completely done laparoscopically, by making a small cut in the abdomen, sometimes, the content do not reduce and dont get back to their normal position. They may be badly stuck, the oesophagus may be having a narrowing because of the chronic acid damage or there may be some bleeding. In such cases, you have to do an open procedure by making a cut through the chest and access the food pipe from above the level of the diaphragm.”
What are the risks associated with the surgery? Dr.Qurban explains, While the laparoscopic procedure, particularly, is safe, you have to keep in mind that there are important organs lying close to the stomach and you only have a small window through which you are doing everything. While damage could occur to these structures like the lungs and heart, in the hands of an experienced surgeon, risk is very minimal.
Dr.Emmatty adds, “The risk of surgery is barely 2% and scope of relapse of the hernia, if the surgical procedure is done neatly, is about 10%.”
Clarifying this aspect, Dr.Qurban reveals, “Speaking of recurrence, there is plenty of it because the repair work involves sutures. If the quality of the patients food pipe is old and the patient debilitated due to other medical conditions, if the patient has chronic cough or has other causes of chronic abdominal pressure, the sutures can give way, resulting in recurrence of the hernia.”
Do diet, alchoholism and smoking have a bearing on hiatus hernia as risk factors? “Not directly, but indirectly, yes, by contributing to acid peptic disease which can aggravate an existing hernia,” says Dr.Qurban.
Is it possible to prevent hiatus hernia? Since in majority of instances, the condition goes unnoticed and is symptomless, one does not talk of prevention, explain the doctors. But, there are preventives to the progression of the condition that is already present in a mild form. While surgery is done only to correct a mechanical defect, the aim is to treat and control the underlying risk factors, prevent acid secretion, avoid heavy weight lifting if hernia is mild and discovered by chance and following surgery, emphasizes Dr.Qurban.