GERD Questions: Hiatal Hernia and Schatzki's ring
I suffer from reflux, underwent an upper GI series, and have been told that I have a paraesophageal hiatal hernia. I have an appointment with a gastroenterologist, but my internist said that I might need surgery. My symptoms aren't that bad. Should I be concerned?
Hiatal hernias are defects in the diaphragm that allow the stomach to slide up into the chest. While they can cause heartburn, generally this is controlled with medications and surgery is not needed. The stomach moves up through the diaphragm right underneath the esophagus. That type of hernia is called a sliding hiatal hernia. The much rarer type, paraesophageal hernia, occurs when the stomach goes through the diaphragm next to the esophagus. Paraesophageal hernias generally tend to enlarge with time, and sometimes the entire stomach is found within the chest. Most patients with a paraesophageal hernia remain asymptomatic. In this type of hernia, symptoms from acid reflux usually do not occur. Instead, the most common symptom is ipper abdominal or lower chest pain. Some patients complain of a fullness in the chest, nausea, and difficulty swallowing. Occasionally, when the stomach slides up next to the esophagus, it can get stuck (incarcerated), leading to loss of bloodflow to the stomach with strangulation or perforation. This complication is potentially lethal, and surgical intervention is necessary. Because of the high mortality associated with this condition, elective surgical repair often is advised whenever a paraesophageal hernia is found. The goal of surgery is to remove the hernia sac and close the abnormally wide esophageal hiatus. Some surgeons then tack the stomach down in the abdomen to prevent it from migrating upwards again, or, they perform a temporary gastrostomy (a hole in the stomach) to help decompress the stomach and anchor it in place in the abdominal cavity. You should speak with your gastroenterologist about a referral to a surgeon that specializes in laparoscopic repair of hiatal hernias.
I suffer from long-term heartburn and have been having difficulty swallowing. The problem is worse with solids than liquids. I have heard that this can be corrected at endoscopy. How does that work?
There are two different issues here. First, anytime someone with long-standing heartburn develops difficulty swallowing, one needs to consider the possibility of esophageal cancer. That is because long-term heartburn can lead to Barrett's esophagus, a pre-cancerous condition of the esophagus that, if left alone, can progress to cancer. Barrett's can be diagnosed with an upper endoscopy, as a biopsy needs to be taken to assess risk of progression to cancer. Once Barrett's and cancer is ruled out, the two most common and benign conditions that cause difficulty swallowing are reflux-induced strictures, and Schatzki's rings. The former is caused by chronic exposure of acid to the lower esophagus, resulting in first inflammation, and then scarring. The latter, the Schatzki's ring, is a muscular narrowing at the end of the esophagus, that is probably either congenital or the result of acid or prior damage to the esophagus by certain pills. The ring typically causes only difficulty swallowing with solids, and can be intermittent. Reflux-induced strictures and cancers tend to cause a more progressive difficulty swallowing, first of solids and then liquids, and can be associated with weight loss. The treatment of benign strictures and rings of the esophagus is to dilate the esophagus. This is typically and most easily accomplished with a balloon that is passed through the endoscope, placed at the stricture, and then inflated with water to attain a pressure effect on the ring or stricture. Results are excellent, and patients are typically swallowing solid food hours after the procedure. You should see a gastroenterologist who can decide what the best treatment option is for your particular case.
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