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This chapter contains a few case histories of hiatus hernia sufferers. They are all typical of the people who suffer from the complaint, though their symptoms differ widely. So if you don't relate to the first story, read on; you will probably see yourself in one of the others. And don't worry if you don't immediately understand all the details of the stories or the terms used. You'll find them explained in later chapters and in the glossary at the end of the book.
Mary's Story
Mary was fifty-eight when she first visited her doctor. Since her children had left home (she had been a full-time homemaker) and her life had become less hectic, she had put on a few pounds, so she had what is politely called a matronly figure. She was about five feet three inches tall and weighed more than 165 pounds.
Her "indigestion" symptoms had started about four years earlier. At first, she'd felt a sharp, raw pain in the center of her chest, with an occasional sour taste in the mouth that came on shortly after meals (or even a cup of tea), particularly when she was putting up her feet. She noticed, too, that the symptoms came on when she bent down, either to get things from beneath the kitchen counter or when she was weeding the garden.
She assumed that all this had to do with her increased weight or her age, or even with the fact that she had started to wear a support girdle-so she decided not to bother her doctor and instead treated herself. She started taking indigestion pills-antacids such as Rolaids[TM]-and, at first, thought no more of her symptoms.
For the first few months, the antacids always eased her symptoms. In fact, they did so very quickly, far faster than she might have expected if the problem were inside her stomach-and that might have given her a clue that the problem was farther up, in her esophagus (the tube leading from the throat to the stomach).
However, this honeymoon period did not last. Gradually she found herself taking antacids every day. The pain lasted longer, came on more often, and was spreading farther up into her chest. To ease it, she started to drink copious amounts of milk and to eat cookies and crackers, which did nothing to help her weight problem. The character of her pain, too, had changed. It was by now clearly recognizable as heartburn-a burning sensation that she felt in a vertical line down the middle of her chest.
Even this was not enough to send her to the doctor. She assumed that heartburn was a common complaint that could be dealt with by over-the-counter medicines, and not the sort of problem with which to bother her doctor. So she continued self-treating with antacids and with servings of milk and cookies.
Two further developments finally brought her to her senses-and to the doctor's office. The first was a persistent, dull ache right in the center of her chest, just behind the inverted V at the lower end of her breastbone. It never seemed to go away completely, and sometimes it woke her at night. The second development was less regular but just as worrisome. The sour taste in the mouth had not only become much more frequent, but it had grown worse. She found her mouth filling with sour, watery material that had apparently welled up from her stomach (a substance known as waterbrash). It was sometimes so bad that it made her choke. Along with this, she found that she could no longer lie flat in bed at night, particularly if she lay on her right side. This invariably produced the waterbrash, and occasionally her mouth filled with the food that she had eaten an hour or so before. This happened one night in her sleep, and she awoke terrified-literally drowning on a mouthful of semidigested milk.
The next morning, in something approaching a panic, she saw her doctor, who had no difficulty making the diagnosis of a sliding hiatus hernia (see chapter 3), but who would have preferred knowing about it at a much earlier stage! Then her treatment would have been easier, and there would have been much less damage to reverse.
Eve's Story
Eve was forty when she noticed her first symptoms. Married with teenage children, Eve was an only daughter whose father, in the later stages of Alzheimer's disease, had recently moved in with her. A worrier at the best of times, Eve's stress after her father moved in became huge, and she was in no doubt that this was a direct cause of her symptoms.
However, her hernia did not show itself in pain or waterbrash. Instead, she had what she described as discomfort-a feeling that the food she had swallowed had not gone all the way into her stomach, but had stuck somewhere in the middle of her chest. Each time she ate, once she felt the sensation, she stopped eating, so meals became a real trial for her. There were times when she could not eat any solid food-indeed, was frightened of doing so, in case it stuck. So she tended to eat only semisolid foods and liquids, believing that they would go down more easily. As they tended to be minced meats and milky puddings, she started to put on weight.
Quite the opposite of Mary's case, however, she found that lying down actually helped her symptoms. Resting, when she could grab a minute, always seemed to allow something inside her to relax and let the food slide into the stomach. Her symptoms never started when she was in bed, and she never had a burning sensation or the flow of waterbrash into her mouth.
Her doctor at the time, worried about the symptom of food sticking in her chest, arranged for a barium-swallow X-ray examination, which showed a small hiatus hernia. This surprised him, as he was looking for other conditions more likely to produce the symptoms of blockage-the main one in women of Eve's age being achalasia, in which the lower end of the esophagus goes into spasm (a form of cramp), which eases with rest. But the barium showed quite clearly a rolling hiatus hernia, so he advised her on that basis. (Achalasia and the different types of hiatus hernia are explained in more detail in chapter 3, along with other conditions with which hiatus hernia can be confused.)
After her father died, and the main source of her stress had gone, her symptoms stopped. For twenty years, they did not return. Last year, Eve-now sixty years old and a healthy woman-developed a severe attack of shingles. Unfortunately, she first noticed the rash, which ran around the right side of her chest over her breast, at midday on a Saturday. Being considerate, she did not want to disturb her doctor on the weekend, so she treated herself until Monday morning with calamine lotion.
This was a mistake; it is vital that shingles are treated within the first thirty-six hours (preferably twenty-four hours) with the antiviral drug acyclovir (Zovirax). Acyclovir damps down the eruption, greatly eases the pain, and, most important, helps the patient avoid the sometimes very severe postshingles pain in the scarred area of skin left by the acute attack.
By Monday, Eve's shingles were a mess. A thick band of pustules and inflamed skin extended from the spine to the breastbone on the right side of her chest, and she was in severe pain and considerable distress. At this point, her hiatus hernia symptoms returned. Once again, eating produced a feeling of blockage. She had to confine her eating to porridge, soup, and custard, as nothing solid would go down. No amount of swallowing, she felt, would "push the food down." One crucial symptom was the pressing desire to belch. She had the ever-present feeling that there was gas in her chest or upper stomach and that she would get relief if only she could bring it up. But she found it impossible to do so. She thought that liquid antacids might help, so she scoured the drugstore for the best-but none helped her. Changing her body position did not help either. She spent hours rolling around in her chair or bed trying to find a position to give her relief from the gas or the "blockage," but it was all in vain.
Her doctor was convinced that the painkillers she was taking for the shingles had stimulated the return of the hernia symptoms. He therefore prescribed a drug to reduce any irritation in the stomach, while continuing with the painkillers. She gradually recovered from both the pain and the hernia symptoms, but it took her more than four months to feel confident enough to eat solid foods again.
Six months after the onset of the shingles attack, she is back to her normal self. She still tends to avoid lumpy foods (she makes sure she chews everything thoroughly before swallowing) and has gotten into the habit of eating several small meals a day, rather than three larger meals, because she feels uncomfortable with a full stomach. She avoids bending down-but only because she has heard that it is not good for a hiatus hernia, not because bending has ever bothered her. She no longer takes any medication and is doing well.
Harry's Story
Harry is sixty-eight and a retired electrician. His symptoms started when he was in his early fifties-with hiccups! They would come on late at night, in bed, just before he dropped off to sleep. He noticed that they were more likely to start if he'd eaten sweets, ice cream, or chocolate just before going to bed (he admitted to having a very sweet tooth). At the same time he felt what he described as discomfort (it wasn't painful or burning) in the upper middle region of his stomach, and a bloated feeling deep in his chest, as if gases were trapped inside it. Like Eve, at times like this he desperately wanted to belch, but couldn't. He assumed that this was just a reaction to eating too many sweet things and changed his late-evening habits. He took a glass of warm milk instead, which helped a little. Even then, the hiccups sometimes occurred when he lay down flat in bed. The only way to relieve them was to get up and walk around or sit up and read. Using extra pillows in bed helped, too. Being propped up at an angle of around 45 degrees kept the symptoms at bay and seemed to prevent the hiccups. After a few restless nights he became more used to sleeping in that position.
Ten years ago, things changed. While at work one day, crawling around under the floorboards of a house he was rewiring, Harry developed a severe pain in the center of his chest, felt very sick, and broke out into a cold, clammy sweat. A doctor was called, and Harry was admitted to the hospital with a suspected heart attack.
However, the hospital tests showed that these new symptoms were actually caused by an inflamed gallbladder, which was full of gallstones. It was assumed that his other symptoms were also related to his gallbladder disease, so when the gallbladder was removed a few weeks later, Harry expected his hiccups and discomfort to disappear. They didn't.
While the surgeons were removing his gallbladder, they checked on his diaphragm and confirmed that he had a hiatus hernia. However, they considered it not serious enough for a surgical repair and left it as it was.
Since then, Harry has been careful. He has had no recurrence of his gallbladder symptoms, though occasionally he still experiences evening hiccups and discomfort. But if he avoids bending over and eating anything after around 8:00 P.M., he remains relatively symptom-free. Recently he has been suffering the odd bout of heartburn, for which he takes one tablet of ranitidine (Zantac) a day, and that seems to help.
Two other changes in his life may also have contributed to his improvement. First, now that he has retired, he no longer must crawl around in confined spaces or lie on a floor with head and chest down a hole, working with electrical wiring. That must be about the worst occupation for anyone with a hiatus hernia! The other is that he has stopped smoking. He is living proof that someone can stop smoking after forty years and feel much the better for it. Doing so will certainly have done his stomach and hiatus hernia a power of good, as well, of course, as his lungs, heart, and blood vessels.
And now that he has retired, he has taken up golf. That keeps him fit, and with the exercise he has shed about twenty-eight pounds. The weight loss, too, may have improved the state of his hernia. He did think of taking up bowling, but was strongly advised against it; bowling is no game for anyone with a hiatus hernia.
Harry illustrates an important point. One in every five people with hiatus hernia has another related illness. The list includes duodenal and gastric ulcers, gallstones, and coronary heart disease, so even if a hiatus hernia has shown up in an X-ray (as in Eve's and Mary's cases) or has been seen during surgery (as in Harry's case), it should never be assumed that any symptoms around the upper stomach and chest are due to the hernia. That pain in the chest could be angina or a heart attack, and a pain in the upper stomach could be from an ulcer or gallstones. So if new symptoms arise, and they don't go away with the usual treatment, or if they are worse than usual, don't hesitate to seek urgent advice. It can often be difficult to distinguish between the pain of hiatus hernia and that of heart attack, but one thing is sure-taking an antacid usually eases hiatus hernia pain very quickly. It will make not a bit of difference to heart pain.
James's Story
James, at fifty, was a fairly stubborn man. A schoolteacher, he had no use for doctors and felt that he could look after himself very well without them. That may have been true when he was younger, but he had a failing that was nearly the death of him. He enjoyed his "little drink" in the evenings. It varied from a scalding hot cup of tea to a neat whisky, neither of which was compatible with his hiatus hernia, which he had treated by himself for many years.
He had started to experience mild heartburn in his late thirties. It was worse just after a meal-which for James, who lived on his own, was usually something quick he fried up himself-so he always kept a bottle of his favorite antacid mixture beside the kitchen sink. A day never passed without a swig from his white antacid bottle.
As the years passed, however, the symptoms worsened. With every meal, he experienced a deep-seated pain behind the lower half of his breastbone, in the center of his chest. It was worst if the food was hot or if he drank alcohol with his meal or after it. Hot tea, a neat whisky, or even a glass of white wine brought it on. At the same time, his heartburn was more severe than before and lasted longer. He was going through more white bottles every week and was also taking anti-indigestion tablets by the dozen.
This deterioration was gradual, so even the new intensity of pain did not cause him to seek his doctor's advice. He had to be shocked into doing that. When he got out of bed one morning, he felt dizzy and faint. He staggered to the toilet, where he passed a stool the color and consistency of warm tar. He looked pale and felt cold and clammy. He knew this could not be right, so he called the emergency number.
It was lucky that he did, because the black stool was a sign of bleeding. The bleeding had come from an ulcer in his esophagus. Over the years, his esophagus had become chronically inflamed from the backflow, or reflux, of acid from his stomach, and the inflammation had eventually eroded into a blood vessel. James had been on the edge of a precipice for many months and now was in immediate danger of dying from a massive internal hemorrhage.
His story has a happy ending. James was rushed to the hospital, where intensive medical treatment saved his life. He is now under constant medical supervision and is being persuaded to change his lifestyle-mainly his eating and drinking habits-by a new partner, who is a much better cook than James is!
James's hernia was complicated by the fact that he also suffered from Barrett's esophagus (also called Barrett's syndrome), a condition in which the lowest region of the esophagus is much more prone than normal to ulceration (explained in more detail in chapter 3). Suffice it to say that the combination of Barrett's esophagus and hiatus hernia can at times be life threatening. Besides causing bleeding, the combined conditions can also perforate, enabling the stomach contents to be expelled into the chest cavity, where they cause a very severe, acute illness. James could have paid for his relative self-neglect with his life.
(Continues...)
Excerpted from Positive Options for HIATUS HERNIA by Tom Smith Copyright © 2001 by Dr. Tom Smith. Excerpted by permission.
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