The Sliding Stomach

Until Pope Pius XII fell ill in 1954, few people had ever heard of hiatal hernia and fewer knew what it was, although surprisingly many must have suffered from it. Nowadays the diagnosis is being made with startling frequency--in 10% to 12% of all patients who have X rays of the upper digestive tract. But is the condition more common than formerly? Probably not, said Harvard's Dr. Herbert D. Adams at a regional meeting of the American College of Surgeons in Boston. The explanation, he suggested, is that the X rays are now being read with greater care and skill. And, he might have added, many more such X rays are being taken.

A hiatus is simply an opening, the word being derived appropriately from the Latin verb hiare, to yawn. The esophagus (gullet), which carries food from the mouth to the stomach, passes through a hiatus in the diaphragm, the muscular wall that divides the chest and abdominal cavities. A hernia is a rupture, or break, usually in a muscle, that permits an organ to protrude through it. A hiatal hernia is an enlarged opening at the point where the gullet goes through the diaphragm. A relatively small hernia will permit the lowest part of the gullet to slide upward into the chest, while a larger one will let part of the stomach slide up (hence the synonym "sliding hernia" for a hiatal hernia). In such cases, some of the stomach's acid contents flow back up into the gullet, causing irritation and inflammation (esophagitis).

Question and Answer. As for an ulcer, the principal prescription is a bland diet, with antacids and possibly drugs to reduce the stomach's activity. One added feature: sleeping with the head of the bed elevated six to eight inches, to discourage backflow from stomach to gullet.

Some babies born with severe internal malformations have hernias that must be corrected surgically to save life. Surgery may also be required for adult victims of chest injuries in which the diaphragm is torn. The question before the surgeons in Boston was to decide when surgery is indicated for the vast majority of in-between patients whose hernias result from a slight innate weakness. The answer depends largely on how successful the surgery will be.

Early surgery for hernia consisted mainly of stitching the diaphragm to restore the hiatus to its natural, former size and putting the stomach back in place. This worked well for most patients, at least for a few months, but after that as many as 25% had a recurrence of their acid reflux. So they were back where they started with "heartburn," which became especially severe while they were lying down, and it was likely to wake them in the middle of the night. Then they spent sleepless hours, propped up in pain.

Correcting a Curve. In the last nine years, Dr. Lucius D. Hill of Seattle's Mason Clinic has succeeded in correcting reflux in all but three of a total of 254 patients, and in only one case was there a recurrence of the hernia sufficient to allow the stomach to slide up. Hill's technique, which is now being adopted by many other surgeons, involves a more elaborate procedure: stitching part of the stomach to form an internal flap that prevents reflux. Ligaments and other tissues are attached where the gullet joins the stomach, so that this junction is anchored permanently below the diaphragm.

Even with the improved technique and results, surgeons concede that operations for hiatal hernia should not be undertaken lightly. Of the patients whose X rays reveal the condition, said Dr. Adams, only about one-fourth need any treatment, medical or otherwise. Only about half of those need undergo surgery. For the rest, there are antacids, perhaps other drugs--and, of course, that infernal bland diet.

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