Have you paid attention to some “common” symptoms?
Mrs. Liu, a 70-year-old woman, came to our clinic six months ago and told us that she has had recurrent acid reflux, belching and burning pain in the upper and middle abdomen for more than 20 years, and had always thought it was a stomach problem. Recently, her symptoms had worsened, with acid reflux causing a chronic cough and a feeling of obstruction after eating, which seriously affected her life. On our advice, she underwent gastroscopy, barium meal and 24-hour esophageal pH measurement to find the culprit of her condition, which turned out to be severe gastroesophageal reflux disease (GERD) and esophageal hiatus hernia. After a successful minimally invasive surgery, Mrs. Liu recovered well and her symptoms have disappeared and she no longer needs to take stomach medication regularly.
Such cases are not uncommon. Some common symptoms, such as heartburn, acid reflux, belching, chest pain or even acid vomiting, hoarseness, foreign body sensation in the throat, chronic cough, etc., are often ignored by patients because the symptoms are sometimes mild and sometimes severe. When these symptoms are not effectively treated for a long time, you should be alerted to the presence of gastroesophageal reflux disease (GERD) and esophageal hiatal hernia.
What is gastroesophageal reflux disease (GERD) and esophageal hiatal hernia? Why do these diseases occur?
Gastroesophageal reflux disease (GERD) is the discomfort and/or complications caused by the reflux of stomach contents into the esophagus. Under normal circumstances, there is a “one-way valve” between the stomach and esophagus that resists the reverse flow of stomach contents. However, when this normal mechanism is disrupted, or when there are abnormalities in the peristaltic motility of the gastroesophagus, reflux symptoms can occur.
Under normal circumstances, the esophageal hiatus in the diaphragm can just accommodate the passage of the esophagus. If the hiatus is enlarged for any reason, the pressure in the abdominal cavity is greater than that in the thoracic cavity, allowing the stomach, omentum and even other abdominal organs to enter the thoracic cavity. This is called an esophageal hiatal hernia. The enlargement of the esophageal hiatus causes disruption of the normal anatomical relationship and may lead to gastroesophageal reflux, causing reflux esophagitis, and in rare cases, herniation of the herniated organ may also lead to entrapment, a condition similar to angina pectoris, or even gastric hemorrhage and necrotic perforation.
What are the types of esophageal hiatus hernia?
Understanding the typology of hiatal hernia is essential for the diagnosis and treatment of the condition. Esophageal hiatal hernia can be divided into three types: Type I is sliding esophageal hiatal hernia (sliding hernia), which accounts for about 70%-90% of all patients, in which the ventral part of the esophagus and the beginning of the stomach move up into the thoracic cavity and the hernia can slide up and down. Type II is a paraoesophageal hernia, which is less common, in which the esophagus and the beginning of the stomach remain in a normal position while the stomach herniates into the thoracic cavity through the weakness of the enlarged esophageal hiatus; type III is a mixed type, in which both type I and II hernia are present, and most of the slip hernia develops into a mixed hernia at a later stage.
What are the clinical manifestations of gastroesophageal reflux disease (GERD) and esophageal hiatal hernia?
Most GERD and hiatal hernias are seen in middle-aged and older patients, except in some congenital cases. Smaller cases of hiatal hernia may be asymptomatic in the early stages, but as the hernia increases in size, it may cause a feeling of obstruction after eating; some patients present with more pronounced GERD. The typical symptoms of GERD are heartburn, acid reflux, belching, and retrosternal pain; sometimes there are atypical manifestations such as acid vomiting, paroxysmal cough, hoarseness, and foreign body sensation in the throat, which can be easily confused with other diseases; in severe cases, asthma and aspiration pneumonia may occur; in addition, severe reflux leading to esophageal ulcer may also cause gastrointestinal bleeding such as vomiting blood and black stool. When type II or III esophageal hiatal hernia hernias become entrapped, necrosis of the hernia contents may occur, resulting in severe clinical manifestations such as increased chest pain, abdominal pain, vomiting of blood and black stools.
How to determine if I have GERD and a hiatal hernia?
The diagnosis of GERD and hiatal hernia relies on a number of ancillary tests to differentiate them from other diseases, as the symptoms vary in severity and often do not have a typical presentation. Gastroscopy, upper gastrointestinal barium meal, and 24-hour esophageal pH test are necessary to diagnose GERD and hiatal hernia. Other tests such as esophageal manometry and gastric emptying tests, as well as tests for cardiopulmonary disease, are also used to differentiate GERD from other diseases.
What are the risks of GERD and hiatus hernia?
When GERD and hiatal hernia are ignored, the patient’s symptoms are often not relieved or the amount of medication taken is not reduced, which increases the burden on the patient and society. Long-term GERD can repeatedly damage the esophageal mucosa, risking serious esophagitis or even cancer, while type II and III hiatal hernia can lead to necrosis of the hernia contents when impaction occurs, resulting in serious outcomes such as bleeding or gastrointestinal perforation.
How to treat GERD and esophageal hiatus hernia?
1.Medical treatment
Most patients with GERD and hiatal hernia have mild symptoms and can be treated internally to control and relieve the symptoms without surgery. However, the recurrence rate is high after stopping the medication, and some patients need lifelong treatment. Internal medicine treatment includes.
1) Change of lifestyle habits.
Changing dietary habits: reducing fat intake, avoiding large foods, and reducing foods that stimulate acid secretion and reflux such as: alcohol, caffeinated beverages, chocolate, onions, spicy foods, mint, etc.
Smoking cessation.
Weight loss.
avoiding sleep for three hours after eating and being more active after eating.
Elevating the head of the bed while sleeping.
Reducing work stress.
2) Taking acid control medications
Most patients can reduce or control reflux symptoms with acid control medications. Commonly used medications are H2 receptor blockers such as: ranitidine, famotidine, etc. and proton pump inhibitors (PPI) such as: omeprazole, esomeprazole, etc.
3) Esophageal and gastric motility drugs
In some patients, the esophageal function test reveals that the esophagogastric emptying ability is reduced, so morbutine can be added to enhance the esophageal and gastric power to relieve the symptoms.
2.Surgical treatment
(1) Indications for surgery: The following four conditions require surgical treatment
Type II and III (paracentral hernia and mixed hernia) with the possibility of hernia impaction.
Type I hernia (sliding hernia) that seriously affects life and is ineffective by medical treatment
Those with severe complications of reflux and extra-esophageal reflux.
Esophagitis with esophageal ulcers.
Esophageal stricture due to reflux.
Esophageal mucosal injury resulting in severe bleeding.
Those presenting with extra-esophageal reflux, e.g., chronic pharyngitis, asthma, aspiration pneumonia, etc.
Barrett’s esophagus, the incidence of malignant changes can be reduced after anti-reflux surgery.
2) Surgical method selection
There are many surgical methods for gastroesophageal reflux disease (GERD) and esophageal hiatal hernia, but whether it is transthoracic or transabdominal surgery, traditional open surgery or minimally invasive surgery, all should include several steps to repair the relaxed esophageal hiatal hernia, lengthen and fix the subdiaphragmatic esophageal segment, and reconstruct the anti-reflux activation mechanism. Due to the anatomical features around the esophageal hiatal hernia, laparoscopic esophageal hiatal hernia repair + fundoplication has now become the gold standard procedure for the treatment of the disease. This surgical approach has been widely accepted by physicians at home and abroad because of its minimal trauma, good repair effect, rapid postoperative recovery and few complications.