Have you ever been told by your doctor that they do not know what is causing you to have shortness of breath or chest pain when you have a normal chest x-ray and a normal EKG? It could be coming from your stomach! Patients with a hernia of their diaphragm, where the stomach and sometimes other organs come up into the chest, frequently experience a whole range of symptoms which can often be very difficult to diagnose. The most common complaints are shortness of breath, chest pain, heartburn, reflux, fullness when eating a meal, gas pains and/or nausea. Many patients, however, have no idea they have a hiatal or paraesophageal hernia!
The medical term for having these organs in your chest is either a hiatal hernia, where the stomach itself slides into the chest or a paraesophageal hernia where a large amount of the stomach and sometimes other organs like the colon or small bowel can move into the chest next to your esophagus. In addition to your stomach slipping into your chest, the junction between your esophagus and stomach becomes loose and can contribute to reflux and heartburn. Usually your physician will recommend several tests for work up. The best studies to diagnose these conditions are upper endoscopy, a series of xrays with contrast called an esophagram, an acid (pH) study and a swallowing evaluation called manometry. Many times they can be seen on a CAT scan as well.
Many patients with long standing heartburn and/or reflux will have changed their diet and their daily and nightly habits substantially. They may use multiple pillows when sleeping, avoid eating before bed, avoid spicy foods, caffeine or chocolate or may avoid eating large meals. When these lifestyle changes no longer help, these patients are typically placed on oral medications to help with the excess acid. Without any intervention, they will need to continue these medications for a lifetime and may continue to have the symptoms listed above even with their medications.
While there are some procedures that can be done through the mouth for very tiny hernias, most of these hernias require surgery for repair. The surgery is either laparoscopic or robotic, both of which utilize small incisions and a camera with long instruments. The surgeon will carefully move your stomach from your chest back into the abdomen. The hernia is then stitched shut so that the only organ passing through is your esophagus, which will help decrease the chance that the hernia comes back in the future.
The junction between your esophagus and your stomach is then reinforced to prevent reflux and heartburn by wrapping a very small portion of your stomach around the esophagus. This is called a fundoplication. Typically, patients only have to stay at the hospital one night after surgery and they can completely discontinue their antacid medications. Additionally, patients with chest pain and shortness of breath usually have immediate relief of these symptoms. After surgery patients will have an altered diet for approximately three to four weeks and will have weight lifting restrictions while they are recovering.
In very rare cases, these hernias can require emergency surgery. The stomach will actually twist over itself in the chest causing significant chest pain, nausea, inability to eat or drink and possibly shortness of breath. This is a surgical emergency as the stomach can lose blood flow and needs to be immediately untwisted. The repair for this is the same and can usually be performed with laparoscopy as well. In severe situations, a part of the stomach may need to be removed. While the stomach twisting is rare, a patient with a paraesophageal hernia should seek care sooner rather than later to avoid this potentially dangerous complication.
Tanya J. Olszewski, MD, is a general surgeon with the Bristol Health Medical Group. She completed training in Foregut Surgery at the West Penn Hospital in Pittsburgh, PA, specializing in hiatal and paraesophageal hernias. She additionally performs laparoscopic and robotic general surgery as well as upper and lower endoscopy. If you think you may be suffering from a hiatal or paraesophageal hernia, you can start your journey toward getting answers today by calling 1-833-4BHDOCS to make an appointment or visit www.bristolhealth.org