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    Hiatus hernia

    Hiatus hernia (sometimes called diaphragm hernia) means that the aperture in the diaphragm through which the esophagus passes, is widened because of a partially-, or completely weakened diaphragm. This is the reason for the most common type of dysphagia, so-called intermittent esophageal dysphagia. This form of dysphagia affects around 10% of the population [1] irrespective of age: young and old. Common symptoms include acidic indigestion, reflux, heartburn, chronic cough, a feeling of 'lump in the throat’ or of a blockage in the chest or difficulties in swallowing solid food e.g. dry meat.

    In this section we explain what hiatus hernia is, its common symptoms, what actually happens in the body, and how the condition can be diagnosed. We also show how nowadays the condition can be treated effectively in a natural way with IQoro® which has a scientifically proven treatment effectiveness. IQoro® is a new and unique neuromuscular treatment method that requires just 30 seconds’ exercise, three times per day. In Sweden, until the summer of 2014 only anti-acid medication was offered to counter the symptoms of the problem, with surgery as the only alternative - with all the risks associated with it.


     

    Common symptoms

    Those affected seldom relate their problem directly to swallowing difficulties - dysphagia - but instead highlight and seek help for the symptoms and problems that hiatus hernia causes; as described below.

    If you are suffering from hiatus hernia you may experience one or more of the following symptoms during or after swallowing. These troubling symptoms may not be present every day, but can come and go.

    • Acid indigestion, heartburn, reflux.
    • Chronic cough.
    • Lump, or cramp in throat, or in the fossa jugularis.
    • An intermittent feeling of a blockage in the chest.
    • Difficulties in swallowing some solid food: including chicken, dry meat, rice or soft dry bread.
    • Food stuck in the throat more often than normal.
    • Feeling ’full up’ earlier than was normal.
    • Frothy, thick, or excessive saliva that can be difficult to swallow away, which leads to a frequent need to try to swallow.
    • A need to drink a lot of liquid to be able to swallow food.
    • Food that you have swallowed sometimes comes back up to your mouth a while after your meal, sometimes as a violent vomit attack with very thick phlegm.
    • Breathing difficulties.
    • Hoarseness.
    • Bubbly, unclear voice.
    • Gassy, burping often.
    • Pain in the chest or throat: some people experience the pain so intensely that they confuse it with a heart-attack.
    • Pain in the stomach – gaseousness.
    • Pain in the skull behind the ears.
    • Pains in the back.
    • Taking a long time to eat, often worse in the company of others, or in noisy or stressful environments.
    • The problem can become so invasive that you avoid food and drink in social circumstances.

     

    Hiatus hernia is in itself a benign condition of the esophagus but, if untreated, the unpleasant symptoms become more intense over time. More of the above symptoms start to occur and create problems more frequently. Therefore it’s good to start treatment as soon as possible. If you wait too long before treating the problem there is a risk that the musculature will weaken further, which will mean that it will take a longer time to build it up again.
     

    Important note: if it is always difficult to swallow food bites above a certain size

    If it is always difficult to swallow food portions (bolus) larger than a certain size, and you have suffered from repeated pneumonia or sudden weight loss, read the section on Achalasia Achalasia cardiae. Hiatus hernia is sometimes confused with the rare esophagus sickness: achalasia. When diagnosed, the condition should always be called by its full Latin name Achalasia cardiae; and nothing else.

    If you can always feel a blockage in the chest when swallowing bolus above a certain size, this can also be caused by some form of narrowing of the esophagus, for example from a build up of scar tissue, the formation of pockets in the esophagus, or a tumour -  so-called constant dysphagia. If you suspect this type of problem you should be referred to a specialist doctor, surgeon or gastroenterologist.


     

    This is how hiatus hernia occurs

    Hiatus hernia is caused by a weakening of the diaphragm, which is a so called skeletal striated muscle (the same muscle type as in your arms and legs) which forms a partition across the lower part of the rib cage up to the breastbone, and separates the chest cavity from the abdominal cavity below (see the horizontal orange line in the diagram). The diaphragm is involved, amongst other things, when we breathe or need to be sick.

    The esophagus passes through the chest cavity behind the heart and down through a small hole in the diaphragm where it leads to the stomach, which is situated just underneath. When we need to be sick and empty our stomach, our stomach should normally slide up through the hole in the diaphragm. When we have been sick the stomach should return to its normal position below the diaphragm. In hiatus hernia the diaphragm’s musculature is weakened around the hole where the esophagus flows into the stomach. This leads to the condition where the stomach can randomly slide up and down through the hole and in this way affect both the esophagus’ function and the upper stomach sphincter’s (or Lower Esophageal Sphincter - ‘LES’) ability to close off tightly. At the same time the upper esophagus sphincter or PES (Posterior Esophageal Sphincter) is also affected, so that it does not open completely to allow food down into the esophagus.

     


    Diagram 1 (left) shows hiatus hernia where the stomach has slid up above the diaphragm. See how the upper esophagus sphincter does not open fully when swallowing, because of the crumpled esophagus.
    Diagram 1 (right) shows how the stomach is normally positioned, and how it looks during exercise.

     

     

    The underlying causes of the symptoms

    To transport food smoothly via the esophagus and down to the stomach the longitudinal musculature in the esophagus is flexed or tensed. This creates a stiff tube, and the upper esophagus sphincter opens to allow the food down, see the right hand illustration.

     

    The upper part of the stomach is in the chest cavity

    With a hiatus hernia a part of the stomach lies in the chest cavity instead, see the left hand illustration. The esophagus crumples like a concertina and the longitudinal muscles are relaxed. As a result, the esophagus’ muscles lose the ability to create a stiff pipe and to open the upper esophagus mouth (upper oesophgus sphincter) when swallowing.

    This is the reason for the symptoms of the feeling of a lump-, or blockage feeling, pain in the esophagus, a cramping feeling when swallowing and food becoming stuck in the bend in the esophagus and sometimes being vomited up. Because the upper esophagus mouth does not open correctly there is also a risk that food will become stuck there and then slip into the air pathways. Food becomes stuck in your throat, you will cough, and may have other air pathway problems too.
     

    Upper stomach sphincter remains open and leaks stomach acid

    It is necessary that the entire stomach remains below the diaphragm in the abdominal cavity in order for the upper stomach sphincter to be able to close tightly: the sphincter only opens then in one direction - like a door, and the stomach acids are prevented from leaking upwards. If the stomach mouth is in the chest cavity it instead becomes like a swinging door that opens in either direction.  The upper stomach sphincter opens and stomach acids leak up to the mouth and can even run into the air pathways.

    This leads to the symptoms of chronic coughing, gurgling and indistinct voice, acidic reflux, and viscous frothy saliva. This bubbly saliva is caused by the air pathways creating a thick frothy phlegm to protect the mucous membrane and the vocal cords from the caustic stomach acids. Because the breathing pathways are affected the symptoms are sometimes misinterpreted as asthma. In such cases asthma medicine does not help. The thick frothy phlegm can be difficult to swallow and in some cases can cause pain behind the ears; a consequence of the repeated attempts to swallow.
     

    Other organs are pushed aside

    The stomach, which has slid up into the chest, pushes on other organs like the lungs and heart and can cause pain in the chest. This pain can sometimes be so severe that it is misinterpreted as a heart attack.
     

    Children - hiatus hernia is often misunderstood as a refusal to eat

    In all babies, the upper stomach mouth is naturally situated in the upper position above the diaphragm in the chest cavity. That is why the stomach contents can easily come back up to the child’s mouth with light pressure on the stomach after a meal. Babies born prematurely, or with some other conditions, can often have extra weak digestive tracts.  It is usual that this manifests itself in cascade vomiting after the child has swallowed just a few mouthfuls of breast milk. Feeding the child can be made even more difficult by the fact that the muscle functions in the face, lips and oral cavity are also weakened.

    Normally at around six months of age the esophagus begins to grow in length so that at about one year old the stomach has come down to its normal position under the diaphragm, and the digestive tract slowly begins to function normally. In a few cases the stomach mouth remains above the diaphragm and these children experience the same difficulties as an adult with a hiatus hernia. Hiatus hernia in very small children is often confused with a refusal to eat. For example hiatus hernia can be the reason why a child will drink liquids without a problem, but turn their head away from solid consistencies like meat, soft dry bread, rice or chicken.

     

    Examination – if you suspect hiatus hernia

    Hiatus hernia can cause extremely troubling symptoms, in itself it is not dangerous sickness, but for the victim it can mean considerable suffering. All too often, this can call a halt to social events where food and drink are involved, like a meal with friends. Some victims cannot even work.

    Hiatus hernia can be difficult to diagnose with traditional examination methods like gastroscopy. At the same time there is a lack of knowledge, both in the general public and amongst health care workers, which can lead to the patient being met by scepticism and prejudice. Some will be told that their problem is all in the mind. Research shows, however, that it is extremely important to listen to the patient’s description of the symptoms in order to be able to make the right diagnosis and begin treatment. [2, 3]
     

    Crucial to listen to the symptoms

    Latest research shows that it is important to listen to the person’s description of the symptoms to be able to correctly diagnose hiatus hernia.. [2, 3] Examinations often show a completely normal function despite the fact that the person is suffering from clear and painful symptoms of a hiatus hernia.

    The reason that the examinations sometimes don’t show anything abnormal is that, during the examination, the stomach is not necessarily in the wrong, upper, position - unless it is provoked to be so. These difficulties in discovering the hernia are also a reason why people with these symptoms are often bounced around for several years between various specialists without discovering the cause of the problem. And because people just don’t know, and aren’t aware that even a small such hernia can cause the symptoms as described.
     

    Swallowing x-ray, in prone position, and with provocation

    The best method to discover the hernia is through a swallowing x-ray. To do this, you lie on your side with a pressure cuff around your stomach at the same time as you swallow a barium meal liquid. Despite the efficacy of this method there is still a risk that the hernia will not be discovered, and that is why it is so important to listen carefully to the symptoms. [2, 3]

    Unfortunately X-ray examinations are not always carried out as described, often because of a lack of knowledge around the diagnosing of hiatus hernia. Many patients are asked to sit or stand whilst they drink the barium meal [4].  In such positions it is extremely difficult, if not impossible, to detect the hiatus hernia.
     

    Gastroscopy - looking at the whole canal: from pharynx to stomach

    Gastroscopy, in which a pipe is inserted to the stomach, is possibly the most common examination method for looking at the digestive canal from pharynx to stomach. Gastroscopy is performed to rule out other reasons for the problems and symptoms. Even with this type of examination it is difficult to diagnose a possible hernia, and the examination is experienced by the patient as very uncomfortable. Therefore the swallowing x-ray, see above, should be prioritized from the beginning on suspicion of hiatus hernia, it is less unpleasant, and is also much more cost effective.

     

    Treating hiatus hernia[2,3]

    IQoro® is a new and unique neuromuscular treatment method that takes just 30 seconds’ exercise, three times per day. It is CE marked according to the relevant health, safety, and environmental standards, and is a patented medical device and treatment regime. The treatment is based on more than 20 years’ research and cooperation with the university hospitals of Umeå, Uppsala and Linköping in Sweden.

    IQoro® is unique in being able to simply, naturally, and effectively train the musculature from the mouth down to the diaphragm and treat hiatus hernia. The exercise regime takes 1.5 minutes per day, typically for 6 - 8 months. IQoro® acts against the fundamental causes of why the hiatus hernia and its symptoms have arisen, it does this in a natural way and without negative side-effects. Once the desired result has been reached, exercise training a couple of times a week may still be required to maintain muscle strength.

    Exercising with IQoro® brings into play the lip-, cheek- and pharynx musculature down to the upper third of the esophagus (the buccinator mechanism - a skeletal striated muscle chain), and the stronger muscles at the upper stomach mouth, and the diaphragm. The training results in an increased pressure around the hole in the diaphragm where the esophagus passes through to flow into the stomach. This means that the diaphragm’s strength is improved so that it can hold the stomach down in its correct position, below the diaphragm. As the diaphragm becomes stronger the symptoms shown above are naturally reduced or disappear completely.
     

    How quickly will I notice the results?

    According to a study published in the World Journal of Gastroenterology, all patients with diagnosed hiatus hernia, or symptoms of 'esophagal dysphagia’, improved after 6 to 8 months’ training with IQoro® for just 1.5 minutes per day. The people that participated in the study were from 19 – 85 years old and had shown the symptoms for between 1 to 15 years – median 3 years - before treatment with IQoro® commenced.

    Because hiatus hernia is caused by a weakened musculature it means that the longer you suffer from the symptoms, the longer time it can take to rebuild the musculature. Compare this with taking a long break from jogging, running, or visits to the gym. It is therefore important to start the treatment as early as possible to prevent further uncomfortable symptoms starting. The improvements will be noticed successively: some feel the difference after a few weeks, whilst others may need the entire training period of 6 to 8 months or more.

    Read more about training with IQoro® here.
     

    IQoro® – a readily available treatment that can replace a surgical operation

    Research shows that training with IQoro® is a simple, cost-effective treatment that can replace an operation for hiatus hernia. [2] This that means that everybody, either with diagnosed hiatus hernia, or symptoms, can get treatment immediately.

     

    General advice for relief before

    the full effect of IQoro® is achieved

    IQoro® treats the causes of hiatus hernia with scientifically proven effect, note however that the following general advice is only for relief of the symptoms.

    • Raise the head of your bed about 15 cm and lie on your left side, that way the stomach contents cannot come up into your esophagus as easily.
    • If you are overweight, try to slim.
    • Avoid types of food and drink that you know cause you problems.
    • Drink water after every bite.
    • Avoid bending forwards and lifting heavy weights.

       

    Sought help earlier?

    If you have sought help earlier for your symptoms, but have only been offered anti-acid medicine to relieve the problems that hiatus hernia causes, there is now a proper treatment. The IQoro® product and its exercise regime has been available in the Swedish system since the summer of 2014, but it is still widely unknown in most parts of the world. Therefore we recommend that you take information about treatment with IQoro® on your next visit to your healthcare professional.

    Earlier, anti-acid medication was the first step in treatment to relieve the symptoms of acidic indigestion, heartburn and reflux. If that didn’t help, which it seldom did completely with hiatus hernia, a surgical operation was the only alternative available. In such an operation – which is expensive and always carries a risk - the stomach is sewn fast under the diaphragm, which contributes to unwanted side-effects. [2] If, for example, a person needs to vomit after such an operation this cannot happen in a natural way, hospitalisation is required and a catheter is inserted down to the stomach to empty the contents [5].

    The operation has therefore only been offered to those that are worst affected, which means that many suffer, and have suffered for a long time, from these serious symptoms. Symptoms that affect everyday quality of life and the possibility to enjoy mealtimes with others.

    Now IQoro® is available to offer a simple treatment which is cost effective, simple to administer, and without any negative side effects. People with hiatus hernia and its troublesome symptoms do not need to suffer any longer. Read more here on how the treatment method works.

    Hiatus hernia

    Hiatus hernia

     

     

    Malin Wallin

    Malin’s swallowing difficulties became a torment

    Malin Wallin, a 25 year old has always been slim but has never had a problem with eating. Until her last year in high school that is, when - without any warning - she began to be affected by a persistent feeling of having a lump in the throat and trouble with swallowing. It would take several years before she would be helped by a new treatment method in the form of a neuromuscular exercise device and regime from IQoro®.

    It is a very modest young lady that turns up to the interview to tell us about her tough years with swallowing difficulties, difficulties that of course have caused anxiety, worry and social isolation at many shared mealtimes.

    - For many years it has been a torment to eat in the company of others. I carried with me a constant fear of having something stick in my throat, and I avoided mealtimes with colleagues or friends, says Malin, who now works as a childcarer...
     

     Read patients' own stories here

     

     

    Niklas Gerholm

    Niklas’ feelings of constant queasiness are gone

    Niklas had dieted with the LCH method and lost weight, but he was afflicted by a reflux problem (LPR) when he went back to an ordinary diet.

    Food leaked up from his stomach at night giving a feeling of queasiness and an irritating, persistent, dry cough. After he had researched the problem, Nicholas concluded that he was suffering from dysphagia, or swallowing difficulties.

    –  It was always gurgly in my throat and the swallowing difficulties came more intense, says Nicolas.

    In the end, he sought professional help and underwent a gastroscopy, but nothing abnormal was to be seen.

    –  It was frustrating! Sometimes I couldn’t even sleep at night because it felt as though the remains of my food were still in my esophagus, and were leaking up into my throat.
     

     Read patients' own stories here


    Text by: Dr. Mary Hägg, Doctor of Medicine, Post-doctoral researcher at Uppsala University specialising in orofacial medicine, Head of Department at the Speech and Swallowing Faculty: Ear, Nose and Throat Clinic at Hudiksvall Hospital, Sweden. Registered Dentist. In cooperation with MYoroface.

    December 2015. (Translation from the original Swedish text by T.W.Morris, MYoroface.)


    Sources:

    1. Kjellén G, Tibbling L. Manometric oesophageal function, acid perfusion test and symptomatology in a 55-year-old general population. Clinical Physiology. 1981; 1:405-15

       

    2. Hägg M, Tibbling L, Franzén T. Esophageal dysphagia and reflux symptoms before and after oral IQoro® training. World J Gastroenterol 2015; 21(24): 7558-7562.

       

    3. Hägg M, Tibbling L, Franzén T. Effect of IQoro® training in hiatal hernia patients with misdirected swallowing and esophageal retention symptoms. Acta Otolaryngol. 2015 Jul; 135 (7):635-9.

       

    4. Nin CS, Marchiori E, Irion KL, Paludo Ade O, Alves GR, Hochhegger DR, Hochhegger B. Barium swallow study in routine clinical practice: a prospective study in patients with chronic cough. J Bras Pneumol 2013; 39: 686-691 [PMID: 24473762 DOI:10.1590/S1806-37132013000600007]

       

    5. Tibbling-Grahn L, broschyr 03 Svenska Dysfagiförbundet, Stoppar maten upp i bröstet när du äter?

      Mellangärdesbråck – En vanlig matstrupssjukdom i alla åldrar. (pdf).
      (English translation, “Does your food get stuck in your chest when you eat? Hiatus hernia – a common esophagus condition that affects people of all ages”)

     

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