Achalasia, Heartburn and Hiatal Hernia

Problems of the Esophagus and Stomach

  1. Heartburn (Gastroesophageal reflux)
  2. Hiatal hernia
  3. Achalasia

Anatomy and Physiology

The human digestive or gastrointestinal tract helps manage food and wastes.

It begins at the mouth where food is swallowed past our throat down to a swallowing tube called the esophagus. The esophagus passes food across a valve called the lower esophageal sphincter (LES, also known as the “heartburn” valve) into the stomach. The stomach acts as a reservoir to hold large volumes of food and water. The stomach creates acid to help kill any bacteria or other organisms that are ingested with our food. The stomach also helps churn the food to break it down to make it easier to digest. The stomach gradually releases our food into the small intestine across a valve called the pylorus. The small intestine serves to do most of the absorbing and digesting of our nutrients. Eventually the nutrients are exchanged and wastes are brought into the intestine and the small intestine passes across a valve called the ileocecal valve into the colon. The colon acts as the final path for our wastes. The colon’s job is to mainly absorb excess water so that we do not become dehydrated and allows us to pass our waste as solid stool. The rectum is the last part of the colon and it acts as a reservoir to allow us to hold our stool until we can evacuate it at a convenient time by relaxing our anal sphincter.

We are designed with valves along our digestive tract (the lips, the throat, the heartburn valve, the pylorus, the ileocecal valve, the anus) to help control the flow of food towards digestion and waste products towards elimination with bowel movements.

Sometimes these valves can become worn out or not function properly. Improperly working valves can result in several problems. Sometimes the valves can be too strong such in a condition called achalasia where the heartburn valve will not relax and patients can have problems with swallowing. On the other hand, sometimes the valves are too relaxed and allow contents to reflux backup such in the case of heartburn or Gastroesophageal Reflux Disease (GERD) across the lower esophageal sphincter or heartburn valve.

The diaphragm is a blanket of muscle that stretches across our lower ribs and our spine to help keep our heart and lungs in our chest and separate those organs from our abdominal organs such as our stomach, intestine, colon, liver, spleen, and pancreas. This allows us to have two different environments in our body. To help us breathe the diaphragm contracts in a way along with our ribs to help make our ribcage larger and create suction like a vacuum cleaner to allow our lungs to expand and suck in air. In other words, the chest is designed to have negative pressure. In our abdomen, our diaphragm and stomach muscles contract to create positive pressure such that we have the ability to forcibly expel air such as coughing or sneezing or even expel contents such as vomiting, bowel movements, or urinating.

Our digestive tract has adapted to use the negative pressure of the chest and the positive pressure of the stomach to work properly.

  • Gastroesophageal disease
  • Heartburn
  • Reflux

Gastroesophageal reflux disease (GERD) is commonly known as heartburn or reflux occurs when the lower esophageal sphincter or heartburn valve cannot or does not work properly.

The swallowing tube or esophagus helps push food from the mouth down towards the stomach. It is very soft and pliable and is not designed to handle acid or bile or other digestive contents.

The heartburn valve (lower esophageal sphincter or LES) between the esophagus and stomach helps protect the esophagus by remaining closed at regular times and only opening up when food passes from the esophagus to the stomach. The heartburn valve usually rests just below the diaphragm where the positive pressure of the abdomen can help keep the valve squeezed shut.

The stomach is designed usually to help push food downstream into the intestine.

Gastroesophageal reflux disease (GERD), more common called “heartburn” or “reflux” occurs when one or more of these areas (esophagus, heartburn valve, stomach) do not work properly. For example:

The esophagus cannot squeeze or empty properly and therefore it cannot clear out the normal mild reflux that the esophagus typically sees and pushes back into the esophagus.

The heartburn valve (or lower esophageal sphincter) does not close properly or is too weak and opens up more frequently to allow the stomach acid contents to reflux up into the esophagus causing injury to the esophagus’ inner lining often reflected as heartburn or pain. Sometimes reflux can be high enough to go into the windpipe or lungs giving chronic bronchitis or pneumonia, go up into the throat giving hoarseness and current throat infections, or reflux even as high as up into the nose and sinuses giving chronic sinusitis.

If the stomach does not empty properly and food cannot go downstream into the intestine, increased stomach pressure will push on the heartburn valve and force the heartburn valve open causing greater wear and tear on the heartburn valve. This is called delayed gastric emptying or gastroparesis.

Patients with heartburn or reflux complain of a burning pain that starts below their breastbone and radiates up into their chest. Often they have more belching. The reflux is often more worse when they bend over or cough and strain. Sometimes they can get an acid/brackish taste in the back of their mouth. Spicy foods or acidic food (such as tomatoes, orange juice, and carbonated beverages such as Coca Cola, which contain carbonic acid) often set off flares as well. People will often get heartburn especially at night when they are lying down flat and will try maneuvers such as sleeping propped up on many pillows or actually propping the head of the bed up on posts to decrease the chance of feeling heartburn. People often have problems with bad heartburn if they eat just before going to bed and often have to adapt to having smaller meals and waiting several hours after a meal before going to bed to sleep.

Sometimes the reflux of acid and other digestive juices up into the esophagus can severely damage the esophagus and cause esophagitis. This can result in bleeding, pain, and spasms of the esophagus, which can be very uncomfortable. Sometimes with acid damage over many years and chronic esophagitis the esophagus tries to adapt by trying to change its lining to that of the intestine to protect itself. This is called Intestinal Metaplasia or Barrett’s esophagus.

The presence of Barrett’s esophagus increases the risk of cancer of the esophagus 40 times the normal risk.

Hiatal Hernia

Reflux also occurs in the presence of a hiatal hernia. A hiatal hernia is an abnormally large defect in the diaphragm. In order for food to get from the mouth into the abdomen it needs to pass through an opening in the back of the diaphragm large enough to allow the esophagus to pass through. This opening is called the esophageal hiatus. Sometimes that opening can become enlarged or dilated allowing the positive pressure abdomen to push its abdominal organs up into the chest. This is called a hiatal hernia (or a Paraesophageal hernia). Because the stomach is right near that area the stomach is usually the first organ to herniate into the chest. As the stomach herniates so does the heartburn valve. With the heartburn valve now in the negative pressure chest it cannot stay closed as well and it cannot function properly. Most hiatal hernias usually result in the stomach sliding out of the chest (Type 1 paraesophageal hernia). When the stomach climbs into the chest as in a hiatal hernia, often the stomach cannot empty properly and this can also result in bloating, nausea, and vomiting. The rubbing of the stomach across the hiatal opening can irritate the inner lining of the stomach resulting in ulcers (Cameron’s ulcers). Some people can vomit blood. Sometimes the stomach can get pinched off or kinked or twisted (gastric volvulus or incarceration) and this can result in severe pain as well. Fortunately most hiatal hernias are not severely symptomatic. However the presence of a hiatal hernia considerably increases the risk of having heartburn problems as well as other problems that can be unpleasant and even seriously harmful.

Medical Treatment

Medical treatment for heartburn or gastroesophageal reflux disease (GERD) is to make the stomach and digestive juices less damaging (and therefore less painful) to the esophagus. The main way to do this is to block acid production. Most people with heartburn have this controlled with over the counter medications such as Maalox, Tums, or Rolaids. With the advent of more recent acid blocking medications such as the H2 blockers (Tagamet, Zantac, Axid, Pepcid, etc.) and proton pump inhibitors (Protonix, Prilosec, Omeprazole, Prevacid, Nexium, AcipHex, etc.) ulcer and reflux problems are much better controlled. Other medications such as Carafate coat the stomach lining and help protect it against acid exposure. If the stomach has poor emptying as in gastroparesis or delayed gastric emptying, adding agents to help the stomach empty better such as Reglan (Metoclopramide) or low dose Erythromycin can sometimes be of help.

Most patients with behavior changes and diet changes and medications have can better tolerance to their reflux disease, however, sometimes this is not adequate.

Surgery focuses on the reconstructing the heartburn valve. Rudolph Nissen first did this in 1951 when he used the top part of the stomach to wrap around the lower part of the esophagus as a patch to help repair a hole in the lower esophagus. The patients came back stating they had no more heartburn. Initially this was performed as an open procedure however with the advent of laparoscopic (minimally invasive surgery or keyhole surgery) techniques the surgery can be performed through five tiny incisions.

The main goals of surgery:

  • Ensure that the lower esophageal sphincter (or heartburn valve) is located in the abdomen
  • The diaphragm is closed down snugly so the opening is not large enough to allow herniation of the stomach or other contents
  • Taking the top part of the stomach (the fundus) and wrapping it around the lower part of the esophagus. Use stitches (or plicate) to create a one way nipple-like valve -hence the term fundoplication (“stomach stitching”).

The surgery requires general anesthesia and operative time usually takes about 2-3 hours. Patients usually stay overnight. Initially the rebuilt heartburn valve swells and will tighten. As a result, the patient can only tolerate liquids and blenderized foods for the first few weeks. After about two weeks the valve swelling backs down and patients can begin to tolerate soft foods and gradually advance to more solid foods and then tougher solids such as steaks and breads.

At five years, 90 to 93% of patients have excellent heartburn control not requiring any medications. At ten years the number goes from about 85 to 90%. Conversely, 5 to 15% of patients still may need occasional medications or daily medications to help control their heartburn and reflux. In the majority of these cases, symptoms are much easier to control after surgery. This surgery is best performed by people with training in advanced laparoscopic surgical techniques who perform these procedures regularly.

There are risks to surgery. Anytime anyone goes into the operating room there is always a risk of a stroke, heart attack, deep venous thrombosis, pulmonary embolism, or death. More common concerns with this surgery are the inability to vomit due to the tightened heartburn valve and bloating and increased flatulence. It can be hard to burp initially but the vast majority of people usually can belch pretty regularly after a couple of weeks. There are risks of bleeding, need for a transfusion, infections at the skin or an abscess in the abdomen or chest, spleen injury with possible need for a splenectomy, esophagus or stomach injury requiring stitches or repair, converting to an open incision, breakdown of repair with recurrence of reflux or herniation, injury to other organs, prolonged pain or nausea, need for endoscopy and dilations, need for reoperation as well as other risks. Fortunately these risks are not too common and usually are short-term or controllable.

Diagnosis

Although patients can present with classic symptoms of heartburn, it does not necessarily mean that they have reflux disease. Therefore, a thorough workup with testing is essential to identify which patients truly have gastroesophageal reflux disease and would benefit from surgery. Sometimes esophagus or stomach disorders can mimic symptoms of heartburn. Studies help determine the cause(s) of a patient’s problems.

A typical workup includes:

  • Upper esophagogastroduodenoscopy (EGD)

    This procedure involves using a flexible snake-like camera scope that is passed through the mouth under sedation to look at the inner lining of the esophagus, the heartburn valve, the stomach, and the first part of the small intestine. This can show evidence of a hiatal hernia, esophageal or stomach damage such as esophagitis, gastritis, stomach ulcers, duodenal ulcer, and other abnormalities. This is typically performed by a gastroenterologist but it can also be performed by experienced medical physicians and is commonly performed by most general surgeons as well.

  • Esophageal manometry

    This test involves passing a catheter down the esophagus and having the patient take several swallows to see how well the swallowing tube or esophagus pushes liquids and foods down towards the stomach. Usually the esophagus pushes material in a nice coordinated effort (peristalsis).

    However, in some cases the esophagus it too weak to squeeze (achalasia) or squeezes too hard (nutcracker esophagus) or does not squeeze in a coordinated fashion resulting in spasms (diffuse esophageal spasm or ineffective esophageal motility). The importance of this test is to make sure the esophagus is strong enough to push liquid and food across the reconstructed heartburn valve.

    In the case of the esophagus having very poor motility or the esophagus being very weak, sometimes a partial stomach wrap (Toupet, 270-degree) as opposed to the typical complete 360-degree wrap (Nissen) is needed. This is not necessarily as strong of a heartburn repair but lessens the risk of severe problems with swallowing of liquids and foods (dysphagia).

  • 24-48 hour pH monitoring

    This test looks at the level of acid exposure to the lower esophagus. Sometimes this requires a small wire worn in the esophagus overnight. Newer studies use wireless probes. Patients are sent home with a diary to write down what foods they eat and what symptoms they experience. These tests are often performed while the patient is not taking antacids. This test is the best test to determine who will benefit from surgery and it gives a good baseline helps give a sense of how severe their reflux truly is.

  • Barium swallow or upper gastrointestinal study

    This study involves swallowing liquid contrast that can be seen on x-ray and looks how well the liquid passes from the mouth down the esophagus and into the stomach. It can look for anatomic abnormalities such as hiatal hernia, strictures, masses, or other concerns.

  • Gastric emptying study

    Sometimes this is needed to determine how well the stomach empties. This study involves giving liquid and food traced with a radioactive label that can be seen on an X-ray machine. The stomach is viewed at 15 to 30 minute intervals to see how long it takes for the stomach to empty properly. If the stomach has very slow emptying sometimes medication or even a surgery is needed to allow the stomach to empty better and prevent wear and tear on the reconstructed heartburn valve. Typical symptoms of delayed gastric emptying include bloating, feeling full very early after one or two bites of the meal, chronic constipation, or frequent vomiting.

Patients with evidence of damage to their esophagus based on endoscopy and/or pH studies and with good esophageal muscle function by normal manometry are patients that can benefit from having surgery. If you are interesting in seeing if surgery is appropriate for you please contact our office.

SCG/em

Achalasia (“failure to relax”)

A disorder of the swallowing tube, or esophagus, characterized by the lower esophageal sphincter or heartburn valve not being able to relax and the esophagus is not able to push food from the mouth down into the stomach. This chronic blockage by an unrelaxing, tight valve results in dilation and weakening of the esophagus swallowing tube. Symptoms typical for achalasia are a worsening ability to swallow foods and liquids. Usually foods become more difficult to swallow and offer require large volume of liquid to help push the food across the tight lower esophageal sphincter into the stomach. Patients often can have chronic vomiting and have problems with reflux when lying down or reflux of foul food and regurgitation. Sometimes swallowing can be very painful as well. Sometimes the esophagus can have spasms as it tries to push past the blockage resulting in occasional chest pain as well. Untreated the blockage can become so severe that patients can eventually starve to death.

Unfortunately there is no treatment that completely cures achalasia. There are means to help control the problem and make the esophagus work better and make life much more tolerable. Most therapies focus on trying to get that valve to open up better. Attempts of using medication only such as calcium channel blockers or Nitroglycerine based products that typically relax muscles have not been shown to be effective in this case since the heartburn valve muscles are often very scarred and cannot relax. Endoscopic techniques involve passing a balloon across the tight heartburn valve and blowing it up (pneumatic dilatation) to help tear the heartburn valve more open. This can be an outpatient procedure and be effective, but there are risks of possible tearing completely through the esophagus (perforation) requiring emergency surgery. There has been interest in using botulism antitoxin (Botox) to help deaden the muscles and relax the heartburn valve. While this has been shown to have some short term benefit, the effects of the Botox therapy wear off within weeks to months, leaving the patient with having problems swallowing again.

The classic surgical approach is to cut the thickened and scarred muscle fibers of the heartburn valve while keeping the inner lining intact. Because the heartburn valve is completely destroyed patients often have severe heartburn and reflux and therefore usually a partial heartburn valve reconstruction (Dor fundoplication = anterior 180 degrees versus a Toupet fundoplication = posterior stomach wrap 300 degrees) is made. As a result, patients get some better control of heartburn and reflux but not have the valve too tight for the weakened esophagus muscle to push liquid and food across. This was initially done through an open incision but can be done with a few tiny incisions using laparoscopic techniques. This type of surgery can be done in two to three hours under a general anesthesia and patients usually go home after one or two days. Patients typically feel swallowing relief rather quickly. Patients often have a better surgical result and better repair if they are treated with surgery initially as opposed to repeated dilations.

Diagnosis and workup of this condition involves studies to help better delineate the esophagus and stomach anatomy and function.

Tests include:

  • Barium swallow or upper gastrointestinal study

    This study involves swallowing liquid contrast that can be seen on x-ray and looks how well the liquid passes from the mouth down the esophagus and into the stomach. It can look for anatomic abnormalities such as hiatal hernia, strictures, masses, or other concerns. Classic presentation of achalasia on swallowing is a very dilated esophagus that tapers off to a very tiny opening in the heartburn valve (“bird’s beak” appearance).

  • Esophageal manometry

    This test involves passing a catheter down the esophagus and having the patient take several swallows to see how well the swallowing tube or esophagus pushes liquids and foods down towards the stomach. Usually this is a nice coordinated effort but in some cases the esophagus it too weak to squeeze (achalasia) or squeezes too hard (nutcracker esophagus) or does not squeeze in a coordinated fashion resulting in spasms (diffuse esophageal spasm or ineffective esophageal motility). The importance of this test is to make sure the esophagus is strong enough to push liquid and food across the reconstructed heartburn valve. In the case of the esophagus having very poor motility or the esophagus being very weak sometimes a partial stomach wrap as opposed to the typical complete 360-degree wrap is needed. This is not necessarily as strong of a heartburn repair but avoids the risk of severe problems with swallowing of liquids and foods (dysphagia).

    The classic findings for achalasia on manometry is a very tight heartburn valve (lower esophageal sphincter) that does not relax or relaxes poorly along with weakened muscle contractions. This is usually the classic way to diagnose achalasia.

  • Upper esophagogastroduodenoscopy (EGD)

    This procedure involves using a flexible snake-like camera scope that is passed through the mouth under sedation to look at the inner lining of the esophagus, the heartburn valve, the stomach, and the first part of the small intestine. This can show evidence of a hiatal hernia, esophageal or stomach damage such as esophagitis, gastritis, stomach ulcers, duodenal ulcer, and other abnormalities. This is typically performed by a gastroenterologist but it can also be performed by experienced medical physicians and is commonly performed by most surgeons as well.

    In the event that the above studies are not consistent with achalasia endoscopy can sometimes be of utility to look for retained fluid or evidence of any irritations, ulcerations, or masses.

Sometimes esophageal cancer can present with difficulty swallowing as well.

It is essential that a thorough workup is done to be certain of what is the cause of the difficulty swallowing and pain that can be seen in both achalasia and esophageal cancer.

If you have been diagnosed with this condition and think you would benefit from treatment please contact our office for evaluation.

Hiatal Hernia (Paraesophageal hernia)

A hiatal hernia is an abnormally large hole in the diaphragm.

In order for food to get from the mouth into the abdomen it needs to pass through an opening in the back of the diaphragm large enough to allow the esophagus to pass through. This opening is called the esophageal hiatus. Sometimes that opening can become enlarged or dilated allowing the positive pressure abdomen to push its abdominal organs up into the chest. This is called a hiatal hernia (or a paraesophageal hernia).

When the stomach herniates up into the chest the heartburn valve cannot work properly and patients often have problems with reflux and heartburn. Sometimes the inner lining of the stomach can get irritated and rubbed as it slides in and out of the chest resulting in ulcers and bleeding (Cameron’s ulcers). Some people can vomit blood. Sometimes the stomach can get pinched off or kinked or twisted (gastric volvulus or incarceration) and this can result in severe pain as well. When the stomach climbs into the chest as in a hiatal hernia, often the stomach cannot empty properly and this can also result in bloating, nausea, and vomiting. Most hiatal hernias are small and sliding but some can be quite large and other organs such as the colon and spleen can herniate into the chest as well causing further problems.

 

Fortunately most hiatal hernias are not severely symptomatic. Most small or moderate hiatal hernias can be better tolerated with medicines; but, in the case of severe vomiting, bleeding, or pain a workup to consider hiatal hernia as the cause of the problem must be considered. Some people can develop severe chest pain and therefore a thorough workup to rule out heart problems such as a heart attack or lung problems such as pneumonia or other issues should be ruled out with testing.

Reflux also occurs in the presence of a hiatal hernia. Because the stomach is right near that area the stomach is usually the first organ to herniate into the chest. As the stomach herniates so does the heartburn valve. With the heartburn valve now in the negative pressure chest it cannot stay closed as well and it cannot function properly. Most hiatal hernias usually result in the stomach sliding out of the chest (Type 1 paraesophageal hernia). The rubbing of the stomach across the hiatal opening can irritate the inner lining of the stomach resulting in ulcers (Cameron’s ulcers). However the presence of a hiatal hernia considerably increases the risk of having heartburn problems as well as other problems that can be unpleasant and even seriously harmful.

There is no medical cure for hiatal hernia but sometimes placing a patient on antacids helps the reflux be less irritating and painful and more tolerable. Sometimes medicines are not enough.

The surgical approach to hiatal hernias (paraesophageal hernias) is to dissect the lower esophagus and upper stomach and help reduce the herniated organs out of the chest and back down into the abdominal cavity. Stitches are placed in the diaphragm opening (esophageal hiatus) to help close it down to be a more normal size and stitches are placed to help reconstruct the heartburn valve by taking the top part of the stomach and wrapping it around the lower esophagus to create a one way nipple like valve to help prevent heartburn or reflux. This type of surgery requires general anesthesia and can often be done through tiny incisions using laparoscopic techniques and is performed by a surgeon with advanced laparoscopic skills.

There are risks to surgery. Anytime anyone goes into the operating room there is always a risk of a stroke, heart attack, deep venous thrombosis, pulmonary embolism, or death. More common concerns with this surgery are the inability to vomit due to the tightened heartburn valve. Bloating, increased flatulence, and difficulty in burping are common initially, but the vast majority of people usually improve in these areas after a couple of weeks. There are risks of bleeding, need for a transfusion, infections at the skin or an abscess around the surgery, spleen injury, possible need for a splenectomy, esophagus or stomach injury requiring stitches or repair, converting to an open incision, breakdown of repair with recurrence of reflux or herniation as well as other risks. Fortunately these risks are not too common and usually are easily controlled.