Hernia and Heartburn Unit

Heartburn, also called acid indigestion, usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat and even into the shoulder blades. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste. The burning, pressure, or pain of heartburn can last as long as two hours and is often worse after eating. Lying down or bending over can also result in heartburn and relief is often obtained by standing upright or by taking an antacid that clears acid out of the oesophagus.

Many people suffer from heartburn or acid indigestion caused by gastroesophageal reflux disease. This digestive disease is a disorder that affects the lower oesophageal sphincter - the muscle connecting the oesophagus with the stomach.

Heartburn pain can be mistaken for the pain associated with a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity. In most cases, heartburn can be relieved through diet and lifestyle changes, however, some people may require medication or surgery.

What is Gastroesophageal Reflux?

'Gastroesophageal' refers to the stomach and oesophagus. 'Reflux' means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach's contents back up into the oesophagus. In normal digestion, the lower oesophageal sphincter, which is like a valve, opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the oesophagus. Reflux occurs when the sphincter is weak and allows the stomach's contents to flow up into the oesophagus.

What are the complications of long-term gastroesophageal reflux?

Sometimes gastroesophageal reflux results in serious complications. Oesophagitis can occur as a result of too much stomach acid in the oesophagus. Oesophagitis may cause bleeding or ulcers. In addition, a narrowing or stricture of the oesophagus may occur from chronic scarring. Some people develop a condition known as Barrett's oesophagus, which is severe damage to the membranous lining of the oesophagus. Doctors believe this condition may be a precursor to oesophageal cancer.

What are Hernias?

The most common location for hernias is the abdomen. The abdominal wall - a sheet of tough muscle and tendon that runs down from the ribs to the legs at the groins - acts as a 'corset'. Its function, amongst other things, is to provide strong support to the internal organs which are exerting significant outward pressure. If a weakness should open up in that wall then the corset effect is lost and the stomach and intestines push through the weakness. The opening of a gap in the tissue can occur of its own accord at a point of natural weakness, or by over-stretching a part of the tissue. Over-exertion can cause it, but so could a simple cough or sneeze. The ensuing bulge, which is often quite visible against the skin, is the hernia. The effects felt by the patient can range from being painless, through discomfort, to being very painful indeed.

These hernias commonly occur where there are natural weaknesses in our abdominal wall. Examples of these are the canals (inguinal and femoral) which allow passage of vessels down to the scrotum and the legs, respectively. The umbilical area is another area of natural weakness frequently prone to hernia. Hernias often occur at the site of any previous abdominal surgery.

Hiatus Hernia

There is some belief that a hiatus hernia may weaken the lower oesophageal sphincter and cause reflux and heartburn. Hiatus hernias occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm - the muscle separating the stomach from the chest. The opening in the diaphragm acts as an additional sphincter and the hiatus hernia results in retention of acid and other contents in the part of the stomach above this opening. These substances can reflux easily into the oesophagus. Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatus hernia.

There are no visible symptoms of hiatus hernia, as the whole event occurs inside the chest. People with severe, chronic oesophageal reflux or with symptoms not relieved by conservative treatment may need a more complete diagnostic evaluation.

Doctors use a variety of tests and procedures to examine a patient with chronic heartburn.

 Endoscopy is an important procedure for individuals with chronic gastroesophageal reflux. By placing a small lighted tube with a tiny video camera on the end (gastroscope) into the oesophagus, the doctor may see inflammation or irritation of the tissue lining the oesophagus (oesophagitis). If the findings of the endoscopy are abnormal or questionable, taking a biopsy from the lining of the oesophagus may be helpful.

For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the oesophagus through pH testing. Testing the pH monitors the acidity level of the oesophagus and symptoms during meals, activity, and sleep.

The above procedure are described in more detail on our Gastro-Intestinal Unit page.

The picture shows an axial sliding hernia as seen through a gastroscope. Visible in the background are those parts of the stomach which are protruding into the chest cavity.

Surgery may be necessary if the hernia is in danger of becoming strangulated or twisted in a way that cuts off blood supply, or is complicated by severe gastroesophageal reflux or inflammation of the oesophagus. The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

What can be done to avoid a hiatus hernia?

Whilst there is nothing that one can do to prevent the occurrence of a hiatus hernia, there are three ways of dealing with the symptoms.

Lifestyle
Identify certain foods that may aggravate your condition, then simple avoidance of these foods is an easy way of avoiding discomfort. Avoid such things as:

Hot foods and drinks
Spicy foods
Acidic foods
Foods which are difficult to digest
Smoking
Alcohol
Being overweight
Do not eat a heavy meal prior to strenuous exercise. Try to avoid eating or drinking for an appropriate amount of time before lying down. The occurrence of reflux may be reduced by adjusting the angle of your bed.

The advantage of this approach is, mainly, that you might avoid medical or surgical intervention altogether and be able to live with the condition without suffering the symptoms.

Medicine.
 There are several different medicines available to deal with the symptoms of hiatus hernia. They work in different ways, but are normally of an antacid type, and some work better on certain patients than others.

The advantage of the medicinal approach is that, in certain cases, this allows the patient to avoid all symptoms without too much inconvenience.

Surgery.
No decision should be taken to proceed to surgery for hiatus hernia unless all tests have conclusively confirmed that there is no alternative. The operation involves tightening the hiatus area in order to keep the stomach in its correct place, below the diaphragm, and which reinstates the narrowing of the opening into the stomach.

Inguinal Hernia.

Inguinal hernias occur in the groin area. These hernia operations are among the most common surgical procedures performed today. Although inguinal hernias are most frequent in men, women comprise about 10 percent of the patient population.

Most hernias result from a tear in the deep lining, or fascia, beneath the abdominal muscles in the groin region. Once this lining is torn, the intestines break through the overlying muscle layers pushing up to the skin surface, giving the characteristic bulge. In many cases, this process begins at birth and is an inherited condition affecting people of all age groups. Signs and symptoms that can be associated with inguinal hernias include pain, pressure, burning, bulging in the groin, and enlargement of the scrotum. However, many patients present only with fullness or bulging in the groin without any other symptoms at all.

The traditional method of hernia repair is to admit the patient to hospital, whether as a day-case or for a few days and, under general anaesthesia, the surgeon pushes back the bulge of peritoneum through the opening and then closes the defect by stitching one side of the lining firmly to the other. The patient is restricted in physical activity for some weeks after the procedure to prevent the sutures from pulling apart. In order to reduce the tension of the stitching, surgeons have developed methods of stitching the tissue in layers, one above the other. This technique reduces a little of the pressure. Another technique involves placing or stitching a 'patch' over the hernia.

At the Mayo Day Clinic the most commonly used method is laparoscopic or 'keyhole' surgery. This technique is performed under general anaesthesia and the surgeon inserts small tubes into the abdominal cavity through tiny cuts in the abdominal wall. One tube contains a video camera lens which projects the image of the surgery onto a television monitor. The surgeon performs the repair through the other tubes.  The repair is achieved by firing staples through a mesh patch into the muscle tissue. This approach is often more technically difficult to perform but the advantages of this technique is that only the smallest of incisions are required and the recovery period for the patient is vastly reduced.

Incisional Hernia

Incisional hernias result from the breakdown of a previous surgical incision. These arise most commonly as a result of infection or a haematoma (the collection of blood in an incision) following a surgical procedure. Additionally, tension in the surgical closure of the abdomen can lead to a disruption of the tissues. The result is an unsightly bulge which, left alone, can lead to numerous complications. Some studies have suggested that incisional hernias can occur in as many as 15% to 20% of abdominal operations.

Umbilical Hernia

Hernias at the site of the umbilicus are as a result of the muscles surrounding the naval being weak and allowing the intestine to push through the opening of the 'belly button'. This creates protrusions of varying sizes. A simple procedure is required to suture the abdominal wall closed at the site, forcing the internal organs to remain within the abdominal cavity.