Nov - Dec 2015


By Dwayne V. Smith, MD FACS


Heartburn or GERD (gastro-esophageal reflux disease) may be commonly experienced and is often associated with a hiatal hernia. It may sound simple, but it isn’t always.


First, when symptoms acutely worsen, we need to be sure of our diagnosis. This is often determined in an ER setting if not beforehand. If brought on by spicy or fatty foods it may actually be gallbladder disease which can cause either right upper quadrant abdominal pain or epigastric pain (in the upper midline of the abdomen or lower chest). This can be related to previously asymptomatic gallstones—and/or “sludging” of the bile related to rapid weight loss. More seriously, this epigastric pain may actually be true cardiac pain—particularly in the setting of exercise stress or significant risk factors such as smoking, diabetes, elevated cholesterol, high blood pressure, family history, etc. Hence, it is probably worth discussing with your doctor sooner rather than later to get it properly diagnosed before it becomes severe.


Earlier diagnostic methods may include radiologic upper gastrointestinal contrast study, fiberoptic esophagogastroduodenoscopy(EGD), or intraoperative laparoscopic visualization and repair of the hiatal hernia. Each approach has its strengths. Radiologic and surgical examinations are sometimes better at determining macroanatomy. Fiberoptic EGD can demonstrate smaller intraluminal lesions and inflammatory changes and allows access for biopsy to determine extent of mucosal changes such as pre-malignant (Barrett’s) or cancerous changes if acid reflux has been chronic and severe.


In patients contemplating surgery, treatment may be surgical repair of a hiatal hernia, if present and of significant size, in conjunction with other planned surgery. In post-operative band patients, the treatment may be as simple as removing a little fluid from the band. In other post-op patients, medication may be prescribed—most commonly prescription proton pump inhibitors that are made by numerous manufacturers and also sold over-the-counter in weaker doses. (Protonix®, Prilosec®, Prevacid®, Omeprazole, etc.) While these are very effective for acid reduction on a short term basis, the package labeling (often disregarded by patients and practitioners alike) generally recommends that they be used for only a month or two at a time. Many side effects and drug interactions are described –including interference with calcium absorption and metabolism. This is particularly worrisome in gastric bypass patients who are already known to be at risk for calcium deficiency related to their anatomic changes and decreased calcium absorption.


Just remember an early, accurate diagnosis and appropriate therapy remain the best medicine!