Medical Edge: Diagnosing digestive distress
July 17th, 2007
DEAR MAYO CLINIC: I have a hiatal hernia and take esomeprazole (Nexium) every day. Recently, I had an episode in which I had severe nausea and coughed up some undigested food. What can be done to prevent this? Is surgery an option? — Oklahoma City, OK
Your recent symptoms may — or may not — be related to your hiatal hernia. If the hernia does turn out to be the cause, surgery could be a good option.
A hiatal hernia exists when part of the stomach is within the chest instead of the abdomen. Usually, the esophagus (food pipe) connects to the stomach right at the level of the diaphragm (the breathing muscle that separates our chest from our abdomen). In hiatal hernia, the stomach and esophagus join together at a higher level, above the diaphragm.
Some physicians think people are born with this condition. Others believe acid reflux irritates and shortens the esophagus and pulls the stomach into the chest — causing the hiatal hernia. Another view is that weight gain causes the hernia, with increased abdominal pressure pushing the stomach into the chest. The bottom line is that we really don’t know why people have this common condition.
We do know that small hiatal hernias often don’t cause any problems. Larger hernias may cause health concerns. Some people have much of their stomach up in their chest. The larger the hernia, the more likely it is to cause symptoms.
Years ago, hiatal hernia was used synonymously with gastroesophageal reflux disease (GERD). There’s overlap but they aren’t the same. If you have a hiatal hernia, your risk of GERD is higher, with symptoms such as heartburn, acid regurgitation (especially when lying down), and difficulty swallowing. But you can have GERD without a hiatal hernia, and vice versa.
It’s possible that the nausea and regurgitation of food you describe are symptoms of GERD, but they would be unusual symptoms for that condition.
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Another possible cause of your symptoms is gastroparesis, where food doesn’t leave the stomach as quickly as it should, resulting in vomiting. People with gastroparesis often have GERD, too. In this case, the gastroparesis causes the GERD.
Another possible explanation for your symptoms is a severe motility disorder, such as achalasia, where food collects at the bottom of the esophagus because the esophagus lacks normal muscle contractions that move food along. This is a rare condition and so this is less likely.
Given there are several possible overlapping causes for your symptoms, it’s important to work with your physician to determine a diagnosis and treatment plan.
GERD treatment starts with lifestyle changes and often requires taking medications long term. Eating smaller meals more frequently, avoiding big meals, not lying down right after eating. and sleeping with the head of the bed elevated all can help. So can losing weight and avoiding tight clothing around the waist.
Medication options include antacids, acid blockers and proton pump inhibitors (PPIs). The esomeprazole (Nexium) that you take is a PPI. These medications counter the effects of acid or block its production, and are available both over-the-counter and in prescription strength.
Surgery is another option for long-term treatment of GERD. In a procedure called fundoplication, the top of the stomach is wrapped around the lower esophagus so stomach acid can’t reflux. The procedure often is done laparoscopically, with a tiny incision. A hiatal hernia can be repaired with the same procedure. For patients with a large hernia causing the symptoms, surgery is probably the best option. — G. Richard Locke, M.D., Gastroenterology, Mayo Clinic, Rochester, Minn.
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