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Q: Hiatal Hernia, IBS ( Answered 5 out of 5 stars,   0 Comments )
Subject: Hiatal Hernia, IBS
Category: Health > Conditions and Diseases
Asked by: dee1209-ga
List Price: $100.00
Posted: 07 Mar 2003 10:48 PST
Expires: 06 Apr 2003 11:48 PDT
Question ID: 173190
When I was 38 years old (2000) I went into the hospital for right side pelvic
cramping with a swollen pelvis. It got to the point were I could
hardly lift my right leg. After about a week in the hospital they
released me saying it may have been right colon Diverticulitis.
However, upon seeing my gastro doctor, she informed me it was probably
just a lower colon infection because I was up and about so quickly. I
had a lower cat scat right after and it showed not signs of
diverticulitis. I than had a colonoscopy which showed a few
diverticulosis pockets, a touch of colitis and a spastic colon. So I
had to up the fiber intake, etc because I am always contipated. About
a year later, I started getting severe heartburn which than turned
into severe nausea. I could not put anything in my mouth. My stomach
would start tembeling and this violent feeling of nausea would last
for hours. My sheer will stopped me from vomiting.I had an emergency
endoscopy in Oct 2001 and was diagnosed with severe gastritis and a
hiatal hernia that was inflamed. I was immedialty put on Nexium 40mg,
but remained extremely nauseous for months to come. By the sheer power
of god I never vomited. After about 6 months I would feel good for
about 2 weeks and watched what I ate (no soda, caffine, tomatos
etc.)than the nausea would start all over again, lasting anywhere from
8 hours a day for 3 days and then get better over the the course of a
week or two. Than I would feel better again, then sick again. This
went on & on like this for months. Finally in June 2002, 8 months
later I had 2 months where I had no problems with nausea. Then in
August it started all over again, back to the same 2 weeks on 2 weeks
off. Went back to the gastro doctor and had a Gastric empty scan done.
It came back normal. By the way, I had my thyroid and hormones
checked, all normal. After the gastric emptying scan I was sent for a
PH motility test. The test showed that my esphogus muscle should be at
a level 15, mine was at an 8. Reminder, I also have a large Hiatal
Hernia. The PH level was normal, but I was only off medicine for 3
days, and I should have been off for 5. Medicine was probably still in
my system. After 7 days being off medicine I had severe reflux. Went
back on Nexium 40mg. So, now that the test had been done, I was placed
on Regulan 10mg 3x a day. It worked for 2 days and then the 3rd day
violently nauseaus again. I layed in bed for 5 hours, so sick with my
stomach trembling. Called the doctor and she suggested seeing the
surgeon. He does not want to do surgery for the hernia because of the
LES muscle. He said it could cause more problems, especially with
swallowing. He did not want to chance partial surgery for just the
hernia. Now my docotor is putting me on Tigan for nausea and I am
having a video esophogram done in 1 week. I questioned if this could
be gastritis reoccuring over and over since it is symtomatic with what
I had when the endoscopy was done. She assured me that it was not
since I have been on the Nexium for over 1 year. I'm now on 15mg of
Prevacid and it keeps the heartburn away. I really have no life
anymore. I can't go anywhere for fear that I will vomit. I am afraid
to eat and I don't go to functions if I can avoid it. Sometimes this
nausea comes on within 1 half hour or 2 hours after eating. Could
there be something that the doctors could be overlooking? I also had
an MRI of the brain with contrast in January of 2002 from my
neurologist because I get dizzy sometimes, and everything was normal.
The dizziness has to do with no horizontal saccades present in my eye
movement. So I believe they are 2 separate issues. Anyway, this has
been going on since October of 2001. I am now 41.  Any suggestions?
Subject: Re: Hiatal Hernia, IBS
Answered By: kevinmd-ga on 07 Mar 2003 16:05 PST
Rated:5 out of 5 stars
Hello - thanks for asking your question.  

Although I am an internal medicine physician, please see your primary
care physician for specific questions regarding any individual cases –
please do not use Google Answers as a substitute for medical advice. 
I will be happy to answer factual medical questions.

It sounds like you are having intractable nausea.  Of course, there
are many causes for this - you may want to discuss some of these with
your personal physician.  Please understand that I cannot diagnose you
over the internet.

Possible causes

There are a variety of causes that can cause nausea with and without
vomiting.  To list a few:
- gastroenteritis
- food poisoning
- mechanical obstruction of the stomach, small bowel, colon
- hepatobiliary disease
- pancreatic disease
- peptic disease
- eosinophilic gastroenteritis
- cancer
- gastroparesis
- CNS disease
- psychiatric disorders
- irritable bowel

I will briefly discuss some salient points about possible esoteric
diseases that may cause chronic nausea and vomiting:

An infrequently reported symptom of GERD is nausea. A retrospective
study evaluated 10 patients with intractable nausea and GERD in the
absence of typical symptoms (1). The most notable finding was the
resolution of symptoms in all patients by various GERD related
therapies. These observations suggest that GERD should be considered
as a cause of persistent nausea, even if typical symptoms and
endoscopic findings are absent.

Eosinophilic gastroenteritis:
Benign eosinophilic infiltration of the gut is a rare disorder which
can occur anywhere from the esophagus to the colon, causing symptoms
dependent upon the area and tissue layer of bowel involved. Gastric
mucosal disease is typically associated with nausea and vomiting. 
Endoscopic biopsy is needed for diagnosis. Establishing the diagnosis
is important because of the excellent response to steroid therapy.

Viral gastroparesis:
Approximately 50 percent of patients with chronic idiopathic nausea
and vomiting evaluated in referral centers have gastroparesis (2).  In
one series of 143 patients with gastroparesis, 52 (36 percent) were
regarded as idiopathic, of which 12 were presumed to be "viral
gastroparesis" (3). A viral etiology was suggested in these patients
and in other series when there was an acute onset of nausea and
vomiting with other features of a viral illness (fever, myalgia,
diarrhea, fatigue, or abdominal cramping). In contrast to the
long-term nature of gastroparesis in patients without features
suggestive of a viral etiology, those with viral gastroparesis have
partial or complete resolution of symptoms over time.

Chronic idiopathic intestinal pseudo-obstruction:
Chronic intestinal pseudo-obstruction is a syndrome that suggests
mechanical bowel obstruction of the small or large bowel in the
absence of an anatomic lesion that obstructs the flow of intestinal
contents.  There are four important steps in the evaluation of
patients with suspected intestinal pseudo-obstruction:
- Radiographic testing
- Assessment of nutritional status
- Confirmation of dysmotility with a transit test 
- Performance of specialized tests such as manometry 

Cyclic vomiting syndrome:
Cyclic vomiting syndrome is a disorder characterized by repeated
episodes of nausea and vomiting that last for hours to days separated
by symptom-free periods of variable length. In adults, the disorder
has been described as consisting of episodes of nausea and vomiting
lasting for three to six days in a patient-specific stereotypic

Diagnostic approach

Some of the heterogeneous group of disorders underlying chronic nausea
and vomiting can be identified by directed testing such as a blood
count for eosinophilia, and a neurologic evaluation. Most patients
with unexplained chronic nausea and vomiting should undergo
esophagogastroduodenoscopy to look for esophagitis or gastric outlet
obstruction, and to permit biopsy confirmation of malignancy or,
rarely, eosinophilic gastroenteritis.

However, as in patients evaluated for chronic dyspepsia (a disorder
that often overlaps with nausea and vomiting), endoscopy and other
routine tests are often normal, suggesting an idiopathic (functional)

Let me summarize your diagnostic tests thus far:

EGD --> gastritis and hiatal hernia
gastric emptying study --> negative
24-hr pH test --> negative but you were on PPIs
thyroid and "hormones" --> negative
esophageal manometry --> low LES pressure
brain MRI --> negative

Looking at the picture you have provided, you have 2 obvious reasons
for chronic nausea and vomiting: your low LES pressure and the
presence of a hiatal hernia.  These should be addressed before moving
onto more esoteric causes.

A low LES is connected with hiatal hernias.  From UptoDate:

"One report added credence to the role of hiatal hernia by
demonstrating that patients with larger hiatal hernias have weaker
LES, more reflux, and worse esophagitis than those with small or no
hiatal hernia" (5)

"Thus, although neither hiatus hernia nor a hypotensive LES alone
results in severe gastroesophageal junction incompetence, the two
conditions interact with each other. This conclusion is consistent
with the clinical experience that exercise, tight fitting garments,
and activities involving bending at the waist exacerbate heartburn,
especially after having consumed meals that reduce LES pressure." (4)

The mere presence of an unrepaired hiatus hernia is enough to cause
your chronic symptoms, as the most common symptoms are epigastric or
substernal pain, postprandial fullness, substernal fullness, nausea,
and retching.

There are surgical options to repairing a low LES.  Many surgical
approaches focus on restoring a physiologic equivalent to the normal
LES.  The most common procedures (Nissen fundoplication, Belsey Mark
IV, and Hill repair) claim about an 85 percent success rate in
relieving symptoms and healing esophagitis, although recurrent
symptoms may develop in about 10 percent of initially successful
cases.  These options should be discussed with your surgeon -
obtaining a second opinion would not hurt.


You have 2 clear reasons for your chronic nausea and vomiting: a low
LES and a hiatal hernia.  If they are not addressed, it is likely that
they will continue to contribute to your symptoms.  All options to
treat these conditions should be exhausted before considering other
causes.  Obtain a second surgical or gastroenterological opinion if

Other options that may be considered include i) a CT scan/ultrasound
to rule out any cancer, hepatobiliary or pancreatic disease; or, ii)
improved treatment of irritable bowel (which would be considered
should every other test be negative).

I stress that this answer is not intended as and does not substitute
for medical advice - please see your personal physician for further
evaluation of your individual case.
Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.   
Kevin, M.D.   
Search strategy:  
No internet search engine was used in this answer.  All sources are 
from physician-written and peer-reviewed sources. 

1) Brzana, RJ, Koch, KL. Gastroesophageal reflux disease presenting
with intractable nausea. Ann Intern Med 1997; 126:704.
2) Longstreth.  Approach to the patient with nausea and vomiting. 
UptoDate, 2002.
3)  Bityutskiy, LP, Soykan, I, McCallum, RW. Viral gastroparesis: A
subgroup of idiopathic gastroparesis--clinical characteristics and
long-term outcomes. Am J Gastroenterol 1997; 92:1501.
4) Kahrilas.  Hiatas hernia.  UptoDate, 2002. 
5) Schwaitzberg.  Surgical management of esophageal reflux.  UptDate,

Request for Answer Clarification by dee1209-ga on 10 Mar 2003 05:33 PST
Thank you for answering my question. I wanted to mention a few other
things. I am having a esophogel videogram done on 3/17. What will this
test show? I have also had other blood test that were negative. I need
to clarify with my doctor what they were. My doctor seems to think
that acid is pocketing around the hernia. Could this be possible? I
had hardly any nausea last night and am going to try eating a piece of
bread before every meal. I seem to feel better with more starch. Also
I need to lose about 50 pounds. I am losing weight slowly, but was
told I should have relief when the weight is off, and the hernia will
probably get smaller. You had mentioned Eosinophilic infiltration. I
did have a biopsy done for cancer, H-Plyori and I assume other things
when I had the endoscopy in October of 2001. That was negative. Is it
possible that this was not checked for? Also, I failed to mention that
I just had a sonogram done of my gallbladder, spleen and liver. All
came back negative. Should I still request further testing of some of
the items you had mentioned? Also, with the surgery, my doctor and
surgeon were dead set against it, stating it could cause more
stricture. The surgeon who supposedly has done alot of these surgerys
originally was mentioning fundoplication, but when my Ph tes came back
with the weak muscle he decided against it. Could you elaborate on the
Belsey Mark IV and the Hill repair. Also this type of surgey is it
only for the LES muscle? Thank You.

Clarification of Answer by kevinmd-ga on 10 Mar 2003 06:51 PST
Hello - thanks for your clarification request.  As you have already
been evaluated by physicians, please understand my limitations over
the internet as I have neither met nor examined you. This information
is for patient education only.

Let me address your points:
1) Is it possible that this (eosinophilic infiltration) was not
checked for?

This is diagnosed by biopsy and a blood count showing increased
eosinophils.  If a biopsy was taken, it would be likely that this
diagnosis would have showed up.  As I have not seen the results
myself, I cannot be sure what was or wasn't checked.

2) I am having a esophogeal videogram done on 3/17. What will this
test show?

I am not familiar with this procedure.  There is esophageal videoscopy
that is a laparascopic procedure allowing the physician to directly
visualize the esophagus:
"Laparoscopic Surgery / Videoscopy 

Laparoscopic surgical procedures offer a minimally invasive
alternative to traditional surgery. When a laparoscopic procedure is
performed, only a few tiny incisions need to be made – just large
enough to allow the laparoscope and specialized surgical instruments
to be inserted into the operative area. A tiny camera is attached to
the laparoscope which then transmits images from the inside of the
body to a video monitor, allowing the surgeon to see the operative
area on the screen. "

3) Should I still request further testing of some of the items you had

All the other tests I have mentioned are options that you may want to
present to your physician.  As you have already examined, your
personal physicians would be in a better position that I would to
suggest to correct diagnostic approach.

4) Could you elaborate on the Belsey Mark IV and the Hill repair. Also
this type of surgery is it only for the LES muscle?

From UptoDate:
"The Belsey Mark IV operation involves a partial fundoplication
performed by transthoracic approach, which allows full esophageal
mobilization. The incomplete fundoplication leads to fewer obstructive
symptoms and is therefore recommended for patients with poor
esophageal motility who might have other indications for a
transthoracic approach (eg, obesity or a shortened esophagus).

The Hill procedure involves imbrication of the anterior and posterior
lesser gastric curve around the esophagus with tethering of the
complex to the median arcuate ligament and closure of the diaphragm.
Intraoperative manometry is used to achieve a desired LES pressure.
This operation has also been performed laparoscopically and is
advocated by those who support reconstruction of the angle of His and
the importance of the "gastroesophageal valve" for preventing reflux.
It can also be used in a patient with a small stomach because of prior
gastric resection." (1)

The goal of most surgical options for GERD is to restore a normal LES
pressure.  You may want to discuss options with your personal surgeon.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical
advice - the information presented is for patient education only. 
Please see your personal physician for further evaluation of your
individual case.

Kevin, M.D.

1) Schwaitzberg.  Surgical management of esophageal reflux.  UptDate,

Request for Answer Clarification by dee1209-ga on 10 Mar 2003 08:37 PST
Thank you for responding. The esphogel videogram, is similar to an
upper GI series, one of which I never had. I have to drink a barium
and then eat something. I believe it is suppose to show what happens
to the food after swallowing etc. Any familarity with this? Also, I am
still concerned as to why they are ruling out surgery, especially
since I am in such discomfort.

Clarification of Answer by kevinmd-ga on 10 Mar 2003 11:07 PST
It is possible that we are justing using different terminology.  You
may be referring to videofluoroscopy of the esophagus.  From UptoDate:
"Videofluoroscopy — An alternative to conventional barium studies is
videofluoroscopy, which permits accurate visualization and analysis of
the rapid sequence of events which make up a swallow. It is ideal for
viewing the elevation of the hyoid and larynx, the relaxation of the
UES, and contraction of the pharynx.

The video, taken from both anteroposterior and lateral directions, can
be replayed at much slower speeds or even frame-by-frame to facilitate
accurate analysis. This helps identify abnormal movement of a bolus,
such as aspiration, pooling in pharyngeal recesses, movement of
anatomic structures, muscle activities throughout the area, and exact
oral and pharyngeal transit times. The effects of different barium
consistencies and positions should be tested. Thick or solid boluses
should be used for patients who primarily complain of solid food

Examination during standard videofluoroscopy is limited to the
cervical esophagus. Thus, it does not exclude lesions in the distal
esophagus, which may sometimes give rise to symptoms referable to the
cervical region." (1)

As to why they are ruling out surgery, I cannot comment on that since
I am not involved with your case.  This is an issue that needs to be
discussed with your personal surgeon.

This answer is not intended as and does not substitute for medical
advice - the information presented is for patient education only. 
Please see your personal physician for further evaluation of your
individual case.
Kevin, M.D. 
1) Lembo.  Diagnosis and treatment of oropharyngeal dysphagia. 
UptoDate, 2002.
dee1209-ga rated this answer:5 out of 5 stars
Your information was very helpful.

There are no comments at this time.

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