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Reflux and Hiatus Hernia

Reflux and Hiatus Hernia

The lower part of the oesophagus (food pipe) where it joins the stomach is normally configured to only allow food to go one way – into the stomach.  It achieves this by various mechanisms such as a lower oesophageal sphincter and the shape of the top of the stomach, and prevents acid from travelling back up into the oesophagus.

Gastro-oesophageal reflux disease, or GORD, is a condition where these mechanisms fail, and the stomach acid refluxes back into oesophagus and causes irritation.  This causes burning discomfort in the chest, called ‘heartburn’.  This may be worse when lying down, and is relieved by anti-acid medications such as Nexium or Pariet.  In severe cases food may even regurgitate back up into the throat.  Conditions such as asthma or chest infections may be worsened as some of the acid that comes up may travel down the windpipe into the lungs.

Another part of the anti-reflux mechanism is the hiatus of the diaphragm.  The diaphragm is a large sheet of muscle which separates the lungs from the abdomen and the hiatus is the opening through which the oesophagus enters the stomach.  This may become weakened and enlarged so that part of the stomach, which normally sits entirely in the abdomen, may protrude up into the chest – hiatus hernia.  Sometimes, other organs such as the small or large bowel may even go up into the hernia as well.

A hiatus hernia is often associated with reflux and therefore we consider the two conditions to be related.

A gastroscopy is often the first step.  This is a procedure where a camera is inserted through the mouth to examine the oesophagus and stomach.  It is performed with the patient sedated and is done as a day procedure.  We look for any evidence of inflammation of the oesophagus, presence of a hiatus hernia, and may take some biopsies.

A barium swallow is an x-ray test where you swallow some contrast and a series of x-rays are taken.  This may help to delineate a hiatus hernia or presence of reflux.

Other scans such as CT may also be performed to get information about anatomy of a hiatus hernia.

Oesophageal manometry and pH studies are sometimes also required to measure the degree of acidity and the pressures inside the oesophagus.  These are done by inserting a fine probe via the nose into the stomach.  It is invasive and not all patients tolerate it but it can provide important information.

If you only have reflux which is well-controlled by lifestyle and medications, then you may be happy to do nothing.  Lifestyle changes include losing weight, and avoiding smoking and excessive alcohol intake.

If you have more severe reflux which is incompletely controlled by medications, or you don’t wish to take medications anymore, then surgery is the gold standard to treat reflux.

A very large hiatus hernia will usually cause a lot of symptoms, and has a risk of becoming stuck, or incarcerated, which can be an emergency situation as the stomach can lose its blood supply and die.  It is therefore worthwhile to have a discussion about fixing it.

The anti-reflux operation is called a fundoplication.  This is performed by wrapping the upper part of the stomach (the ‘fundus’) around the gastro-oesophageal junction, which creates a new anti-reflux mechanism.

A hiatus hernia repair involves pulling the stomach and hernia sac back into the abdomen and putting some stitches in the hiatus to make it smaller.  Sometimes a mesh may be placed on it to reinforce it.  A fundoplication will usually also be performed in addition.

Both of these procedures can be done, in the majority of cases, as a keyhole or laparoscopic procedure.

Most patients are able to go home either the same day or next day. You will be able to resume light activities almost immediately. Light lifting, driving should be gradually commenced after one week. Heavy strenuous activity should be avoided for 4-6 weeks.

Haital Hernia

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