Dr James Le Fanu: 7 February
The many thousands of people diagnosed every year as having a ‘hiatus hernia’ might be forgiven for not knowing exactly where in the body the ‘hiatus’ is to be found. The term hiatus is being used here in its literal sense of a gap or opening – the gap being in the diaphragm (the layer of muscle separating chest from abdomen) through which the oesophagus, or gullet, connects to the stomach. A hiatus hernia, then, is a protrusion of the upper part of the stomach upwards through the diaphragm and into the chest.
It is very common, and if looked for, will be found in almost one in three over the age of 60 for most of whom, surprisingly, it has no adverse effects at all. But a hiatus hernia can also cause three main types of symptoms: most frequently the burning pain behind the breastbone or sternum known as heartburn. It may also give rise to an intense boring pain (which can be mistaken for an ulcer) or dyspepsia and an uncomfortable sensation of bloatedness (which can be mistaken for gallstones).
The common theme underlying these disparate symptoms is the reflux of acid from the stomach up into the lower part of the oesophagus whose lining, as a result, becomes red and inflamed – a process best understood by reference to the science of belching. Belching is a very important reflex permitting air in the stomach – which would otherwise have to traverse the length of the gut – to escape back up into the mouth. The belch is the most conspicuous manifestation of the continuous process where a valve at the junction between the oesophagus and stomach (at the level of the diaphragm) repeatedly relaxes to release small pockets of gas.
But, as might be imagined, the presence of a hiatus hernia pushes the valve upwards into the chest, thus the support of the muscles of the diaphragm is lost. The valve as a result becomes incompetent – so not only air but the acidic contents of the stomach whoosh back up into the lower part of the oesophagus – resulting in one or more of the symptoms already described. This is more likely to occur (logically enough) when lying horizontal in bed at night or leaning over to tie one’s shoelaces.
The prospects for those troubled with a hiatus hernia were transformed in the 1970s by the discovery of two potent types of acid suppressant drugs (the best known being Tagamet and Losec), which limit the amount of acid that can reflux up into the oesophagus, thus reducing in ammation and allowing the lining to heal. There is little alternative, when symptoms persist, than to resort to surgery to pull the stomach back from the chest into the abdomen and repair the ‘hiatus’ in the diaphragm. Over the years many different operations have been tried with varying degrees of success – the main drawback being that too tight a repair of the hernia constricts the valve trapping air in the stomach, thus preventing its eructation back upwards, which can be very distressing.
Recently, however, surgeons have refined a technique for repairing the hernia by ‘keyhole surgery’ where fine metal tubes are inserted into different sites of the abdomen, through which delicate surgical instruments are introduced. This technical tour de force is usually followed by a rapid recovery.
Email drjames@lady.co.uk
It is very common, and if looked for, will be found in almost one in three over the age of 60 for most of whom, surprisingly, it has no adverse effects at all. But a hiatus hernia can also cause three main types of symptoms: most frequently the burning pain behind the breastbone or sternum known as heartburn. It may also give rise to an intense boring pain (which can be mistaken for an ulcer) or dyspepsia and an uncomfortable sensation of bloatedness (which can be mistaken for gallstones).
The common theme underlying these disparate symptoms is the reflux of acid from the stomach up into the lower part of the oesophagus whose lining, as a result, becomes red and inflamed – a process best understood by reference to the science of belching. Belching is a very important reflex permitting air in the stomach – which would otherwise have to traverse the length of the gut – to escape back up into the mouth. The belch is the most conspicuous manifestation of the continuous process where a valve at the junction between the oesophagus and stomach (at the level of the diaphragm) repeatedly relaxes to release small pockets of gas.
But, as might be imagined, the presence of a hiatus hernia pushes the valve upwards into the chest, thus the support of the muscles of the diaphragm is lost. The valve as a result becomes incompetent – so not only air but the acidic contents of the stomach whoosh back up into the lower part of the oesophagus – resulting in one or more of the symptoms already described. This is more likely to occur (logically enough) when lying horizontal in bed at night or leaning over to tie one’s shoelaces.
The prospects for those troubled with a hiatus hernia were transformed in the 1970s by the discovery of two potent types of acid suppressant drugs (the best known being Tagamet and Losec), which limit the amount of acid that can reflux up into the oesophagus, thus reducing in ammation and allowing the lining to heal. There is little alternative, when symptoms persist, than to resort to surgery to pull the stomach back from the chest into the abdomen and repair the ‘hiatus’ in the diaphragm. Over the years many different operations have been tried with varying degrees of success – the main drawback being that too tight a repair of the hernia constricts the valve trapping air in the stomach, thus preventing its eructation back upwards, which can be very distressing.
Recently, however, surgeons have refined a technique for repairing the hernia by ‘keyhole surgery’ where fine metal tubes are inserted into different sites of the abdomen, through which delicate surgical instruments are introduced. This technical tour de force is usually followed by a rapid recovery.
Email drjames@lady.co.uk