There is an oval shaped opening in the diaphragm through which the esophagus passes on its way to the stomach. The esophagus is regulated by a sphincter muscle that opens when we swallow to let food into the stomach. Once the food gets there, the sphincter is supposed to close in order to prevent stomach acid from flowing backward. After we swallow, the esophagus contracts (peristalsis) both longitudinally and circularly. This action pulls the stomach upward into the hiatus a little, after which it is then relaxed. If the top of the stomach slides or rolls into the hiatus and stays there, a hiatus hernia occurs. This activity can cause chest pains that mirror cardiac episodes, complete with shortness of breath, which is why hiatal hernia is sometimes called the “great mimic.”
What Causes A Hiatal Hernia?
Sometimes the diaphragmatic muscle tissue surrounding the juncture of the esophagus and stomach is weak, allowing a portion of the stomach to peek through the hiatus. This can also happen from an injury to the area, as when an athlete gets the wind knocked out of him from the shock of being tackled, punched or kicked. It’s possible to be born with an unusually large hiatus, too. Then, there’s the intense pressure from coughing, vomiting, heavy lifting, or straining during bowel movement (Kakarlapudi, 2002) (Puri, 2004).
Heredity is an infrequent factor in hiatal hernia, but obesity (Pandolfino, 2006) and smoking may play a more significant role, particularly in the reflux that accompanies it (Lee, 2001) (Sontag, 1991), where smoking was found to increase pressure upon the sphincter and obesity upon the diaphragm.
Will It Ever Go Away?
There is some evidence that the presence of hiatus hernia contributes to abnormal acid reflux (Dunne, 2000), and that the reverse may also be true. It is believed that acute acid injury can shorten the esophagus and pull the stomach upward, through the hiatus. How’s that for circular reasoning: the acid causes the hernia; the hernia causes the acid? If this is so, avoidance of exacerbating foods might be in order. High-fat and fried foods aggravate reflux by delaying stomach emptying. Fat sits in the stomach longer than other macronutrients and requires more acid to be digested. But you also need to pay attention to spicy foods, creamed foods (including soups), fast foods and even chocolate and milk. Despite being healthy and nutritious, citrus fruits and juices can trigger acid reflux. Tomatoes, caffeinated beverages and alcohol contribute to the misery. Eating smaller meals reduces pressure on the sphincter and the diaphragm. Because surgery fails to solve the problem due to frequent recurrence, it is generally not recommended, although using a mesh of some kind to narrow the hiatus has met a modicum of success (Puri, 2004). Losing weight (if you need to) relieves pressure on the diaphragm and eliminates a significant risk factor for associated esophagitis (Wilson, 1999). One of the non-traditional techniques for easing a hiatal hernia is to drink warm water first thing in the morning, and then stand on your toes and suddenly drop onto your heels, the idea being that the weight of the water will pull the stomach down and out of the hiatus. Who knows?
The frequency of hiatal hernia increases with age, from about 10% in people less than 40 years old to almost 70% in those above 70. Some researchers attribute causation to low-fiber diet, since less-developed societies incur practically no hiatus involvement (Burkitt, 1971, 1981). Others suggest that using chairs and toilets, instead of merely squatting for social encounters and personal needs, contributes to hiatal hernias (Sontag, 1999). Inasmuch as we’re conditioned to the position of our carriages, we might as well increase the fiber and keep the chairs. The Institute of Medicine suggests that we consume 14 grams of fiber for every 1000 calories we take in. Odds are that most Americans fall short. But we know that you don’t.
Are There Supplements?
Because protrusion of the stomach above the diaphragm is a mechanical/structural issue that requires a mechanical/structural fix, we need to focus on reflux sequestration. After you’ve gone through all the antacids on the shelf, starting with Rolaids and working up to proton pump inhibitors like Prilosec OTC, you might explore the alternatives, especially since drugs tend to deplete the body of certain nutrients. In light of that, you may be interested in a licorice preparation called deglycyrrhizinated licorice (DGL), a supplement that has the glycyrrhizin take out because it could raise blood pressure in some people. Licorice enhances mucus production, which is protective against acid (Kolarski, 1987). That’s a good thing. Its derivative, carbenoxolone (Reed, 1978) (Young, 1986), likewise enhances mucus, but has the potential to increase sodium and water retention and to decrease potassium levels in susceptible persons.
Prostaglandins, derived from fatty acids, are hormone-like substances that control various body processes, including the manufacture of protective mucus in the esophagus. Melatonin is a supplement that appears ready and willing to stimulate the formation of prostaglandin E2 and tone down acid reflux via that mechanism (Konturek, 2007). (You might be familiar with melatonin as a supplement to encourage restful sleep.) In the realm of herbal preparations is STW 5, marketed as Iberogast, a blend of licorice root, caraway, lemon balm, German chamomile and other herbs. Double-blind, randomized, placebo-controlled tests found this combination product to be an effective treatment for disturbed digestion (Madisch, 2004) (Meltzer, 2004) without nasty side effects. If you are so inclined to try them, the separate ingredients in this preparation may help to tame heartburn.
The Bottom Line
Lose extra pounds, avoid foods that trigger heartburn, make your last meal of the day two or more hours before bedtime, don’t lie down right after lunch, stop smoking, have smaller meals throughout the day, elevate the head of the bed six inches and try a supplement. Cutting back on sugar and simple carbs might help. And if, like some of us, you have no pride, go ahead and jump up and down on your heels. But put on some rhythmic music first, else all suspicion will be gone.
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