Recent injury on the trail

[Eric Blumensaadt]

Last week I was solo backpack hunting in Lamoille Canyon in Nevada's Ruby Mountains.

My pack, with 11 lb. scoped Browning A-Bolt rifle & ammo strapped to my pack, was just under 50 lbs. (No lectures, please, I had winter clothes, mattress and bag plus a folding bone saw, 10 X LRF binoculars, rolled up plastic deer "sled" and other gear for quartering the deer.)

As I climbed up over the lip of the hanging glacial canyon I noticed pain just below my sternum. I could tell it was a muscular type twisting pain. After pushing on for another 10 minutes and having the pain become more frequent and sharper I made a "command decision".

As Dirty Harry once said, "A man's gotta know his limitations." and with that in mind I headed back down the canyon to camp at its base.

The problem was, I knew from Ski Patrol training, a hiatal hernia when the stomach pushes up through the hiatus, or hole in the diaphragm where the esophagus passes through. My tight waist belt plus the strain of climbing, even with my hiking poles as aids, all combined to push my stomach up against and through the hiatus of my diaphragm. There are two types of hiatal hernias, one being quite dangerous with strangulation of the blood vessels to the stomach, the other a more common "sliding hernia". I monitored my condition for several hours and concluded I had a sliding hernia.

So I continued my (unsuccessful) hunt for another 3 days in the lower 1/3 of the canyon using only an REI Flash UL daypack and experienced no further prolems.

Now I'm scheduled for an endoscopy to assess the damage. I know the surgery will have to tighten up the hiatus but I'm not sure if I will have to limit my lifestyle at all after it heals.

Any docs wish to comment?

[Larry De La Briandais]

I have one, probably had it my whole life. I can get heart burn much easier than most, have stomach aches easier than most, but it has never affected my activity levels. The biggest two problems are a poor diet results in constant stomach upset and severe heart burn if I lay down after a full meal. I need to wait at least an hour before going to bed if I have a full stomach.

I have not had surgery to correct the problem. The symptoms are just too minor and the Dr. that diagnosed the problem felt it was too small to recommend surgery. The only issue with surgery is that my understanding is that there is a high rate of re-occurrence. Now, that was 20 years ago so…

[Dean F.]

Well, at this point you don't even know if you have a hiatus hernia. Worry about options once you actually have a diagnosis, Brother. Heck, this could be simple costochondritis or something.

Paraesophageal hernias (of various types) only account for about 5% of hiatal hernias- these are the dangerous ones you're thinking of. The risk is not terribly acute- conceivably they can result in strangulation of the stomach, but it's certainly not like anyone with a paraesophageal hernia is in danger of dropping dead imminemtly. Yes, it needs fixed. No, it doesn't need fixed RIGHT NOW.

The other 95% are sliding hernias, and not dangerous per se. They tend to get treated because they can lead to bad reflux, which in turn can lead to esophageal metaplasia, which can then be dangerous by resulting in esophageal cancer. But this is clearly a chronic worry, not an acute one- and lots of people have asymptomatic sliding hernias without significant reflux and never have them fixed. You'd have a hard time convincing me (I'm a surgeon) to fix one that was small and asymptomatic with a normal esophageal pH study and scope.

Out of curiosity, why does your doc think it's a hiatus hernia? "Pain below my sternum" is pretty nonspecific and, frankly, would need to have a cardiac problem ruled out first. (Which I assume was done.) Were there other symptoms that you didn't mention? The differential for substernal pain is vast: cardiac, GERD, peptic ulcer, biliary colic, esophageal diverticulum, costochondritis, etc., etc.

And lupus, of course… :)

EDIT— An A-Bolt? Really? Though I guess I shouldn't be critical- my Savage Model 12 weighs 11 pounds WITHOUT the scope.

[BER —]

Agree with Dean. If you presented to my work place (ER), there are several things I'd be worried about before hiatal hernia (also listed in part by Dean). Better to have some diagnostics first and confirm a diagnosis before worrying about potential surgical limitations on your activities. Hope you get it tracked down.

[Eric Blumensaadt]

I'm the one who suggested to my supermodel female GP doc that it was indeed a hiatal hernia.

This was due to the symptoms (muscular-type wrenching feeling with pain just below the sternum and slightly right of the midline) and the presence of a tight pack waistbelt pushing my gut in plus the symptoms occurring only with straining exertion. She agreed that was the most likely problem and ordered the endoscopy. She says that I am in excellent health for a 70 year old with very good BP (115/70), wide window for lowest (45) to highest (130) heart rate and no detectable arterial plaque with yearly ultrasound tests and no cholesterol or weight problem per yearly physicals. Plus 3 years a go I had a complete cardiac workup and passed with flying colors.

I am getting an endoscpoy Monday and go from there to get a few opinions.
If surgery is recommended I will likely go to Los Angeles' Cedars Sianai for it. We have a saying here in Las Vegas,
Q> "Where do you go in 'Vegas to get the best medical treatment?"
A> "The airport."

[BlackHatGuy]

Lucky you. This is the only surgery I've had recommended to me. By my staff, no less….

.

[Eric Blumensaadt]

Doug,

Yeah, seems I too have the PITA personality at times. My wife has recommended that "surgery" for decades.

Tom> "Who is that annoying old bitch?"

Fred> "It's Madeline. She and her husband are the perfect couple."

Tom> "Why?"

Fred> "He's the best proctologist in town and she's the biggest ass."

[jscott]

Hiatal hernias have been linked to atrial fibrillation. I'm not sure of the percentages. With afib, it doesn't necessarily matter that you're in good heart health otherwise (cf lone atrial fibrillation.) Afib can simply be a matter of poor processing of electrical signals from one atria to the other. Apparently, hiatal hernias can effect the electrical signals in your heart. You don't want this!

Ask your doctor.

[Dean F.]

Eric,

You're 70? Brother, unless your "complete cardiac workup" three years ago included coronary angiography you can't really rule out cardiac. You should have at least gotten an EKG. And "pain under my ribs and to the right" is pretty damned protean- as I said, there are a lot of things it could be. Yes, one of them is a hiatus hernia, but worry about that once you have a diagnosis. And, actually, your stomach is a bit to your LEFT though the hiatus is essentially midline. Epigastric/right subcostal pain says gallbladder to me but, y'know, when you're a hammer every problem starts to look like a nail. (I'm certainly not diagnosing you over the interwebs- I'm just trying to point out that you don't have a diagnosis yet. But your doc may well have information that I lack- for instance if you've ever had a CT in the past and so she knew that you already had a small hiatus hernia and just wants to see if it has gotten bigger, etc.)

Now- what if it is a hiatus hernia? Well, as I pointed out, you're 70. If it is asymptomatic and sliding I would propose that you don't need to have it fixed, since something else is likely to get you before esophageal cancer does. Kinda morbid, but that's how you can look at it. Surgery at 70 is itself a bit dangerous, though you do sound healthy from your self-description so you shouldn't outright fear surgery if it comes to that. And even if it is symptomatic- by which I mean it causes reflux- the modern medications for that are DAMNED effective, and they have almost put us surgeons out of the fundoplication business. (Fundoplications are the surgery done for reflux, but are also how we fix HH with the addition of closing the hernia defect somehow- nowadays I prefer biologic mesh.) If you don't have surgery you'd still need surveillance every so often with a scope like the one they have planned for you, since there is some concern that bile reflux can cause problems even without the presence of acid. The only thing that actually no-kidding requires surgery is if they find certain changes in your esophageal lining cells that indicate that they are already changing towards being cancerous, or if the hernia is paraesophageal. (But even that last is a bit contentious- there are studies that show that the risk is probably quite low per annum, so in a 70 year old that risk might be tolerable. OTOH in a 70 year old stomach strangulation is almost certainly fatal in the unlikely event that it does happen.)

If it is any indication, I'm a surgeon and I would take the meds over a Nissen fundoplication if there was any way that I could. That said, it's a good surgery- I just see no reason to take even the small risk involved given that the meds are so effective. I'd certainly find a guy who has done hundreds of them, too, if I needed surgery, because as I said most non-laparoscopic-specialist surgeons don't do a lot of them anymore. I only do maybe a dozen a year. They are fun, though…

Are you still having pain? I ask because pain is an uncommon complaint with HH. Usually the chief complaint is reflux.

[Billy Ray]

I had similar symptoms for over 10 years… along with reflux. Sometimes felt like a fist had hit me right below the sternum. Sometimes it felt like something was tearing. It would come on an hour or so after eating a big meal… could not sit down, could not lie down, would pace around the house… it would take hours to subside. There were many foods I could not eat that would set it off… especially greasy or spicy foods… and eating too much… I would go through bottles of anti-acids with only slight relief… tried the prescription acid pump inhibitors… did not help…

I finally pressed my doctor to scope everything down to my stomach. I was convinced it was a hernia… or maybe even cancer.

The scope came out completely negative. Doctor said everything looked perfect.

Shortly after I was watching PBS and they had a program about pro-biotics and how it could eliminate acid-reflux and digestion problems

I thought what the heck… give it a try.

It was like flipping a switch. Within a day or two the problem was gone and never returned. Of course, this may not be your problem at all. But if they don't find anything with the scope… give it a try…

Bill D

[Eric Blumensaadt]

Dean,

No, I did not have a CA done 3 years ago. Thanks for the reminder and I'll ask to have it included in this year's physical. That test seems to be one of the most definitive tests for blockage problems.

I have no pain currently, even with a 30 lb. pack while fitness hiking in the mountains back of my house. Looks like I'm in for a series of tests. I DO hav full CAT scans of my abdomen and pelvis from last year that I can show to a radiologist. Those were for a disc problem which, thankfully, good physical therapy and continuing home workouts have diminished to almost nothing.

So thanks gents for all the info and advice, professional and otherwise. I'll try the pro-biotics because I have something like GERD maybe three times a month, especially before bedtime. Who knows? Might work for me as well.

[Dean F.]

Egad, Eric, no- angiography isn't really a screening exam. That comment was tongue-in-cheek on my part!

[Anonymous]

"I have something like GERD maybe three times a month, especially before bedtime."

Have you tried eating smaller dinners, and early enough to remain upright for at least 3 hours before lying down? Also, as Dean mentioned, modern anti-reflux drugs, especially the high end PPI's. If all else fails, Dexilant. It's expensive, but far better than having a fundoplication procedure.

@ Dean: I have been told that aggressive management of nausea is one of the follow on requirements of fundoplication? Is this true?

[Dean F.]

@ Dean: I have been told that aggressive management of nausea is one of the follow on requirements of fundoplication? Is this true?

No, not especially. Everyone is nauseated while recovering from general anesthesia- maybe that's what you heard? The classic problem with fundoplication is a wrap that's too tight, leading to difficulty swallowing or belching (which can get uncomfortable). But the vast majority of those cases are temporary, until the swelling goes down.

[Eric Blumensaadt]

@ Dean:

I have a cardiologist friend who had to have 5 bypasses after "passing" a thorough cardiac screening that did NOT catch his blockage problems. Those heart attacks gave him atrial valve damage that ended his career.

That is why I will try to get at least a more definitive screening and an angiogram if warranted. I know it's extreme to do that but I want to know if I really have any blockage(s).

Croaking on the trail is only second to croaking at home in my sleep in terms of where I want to kick the bucket. But I would pity the folks who would have to evacuate my carcass from the trail.

[Anonymous]

"Everyone is nauseated while recovering from general anesthesia- maybe that's what you heard?"

No. I probably should have phrased my question more clearly. Background: I have been on PPI's since 1999, and they have, as you said, been damned effective. However, having grown increasingly concerned about the long term effects of using them, I consulted Dr. Ralph Aye, a noted surgeon up here in Seattle, about the fundoplication procedure. He worked under Dr. Lucius Hill when the Hill procedure was being developed/refined, and understandably tends to favor that variant of fundoplication. During our discussion, he mentioned that long term aggressive control of vomiting wth anti nausea meds was necessary, in his opinion, to reduce the chance of compromising the sutures. I know opinions vary from surgeon to surgeon, so I am always looking for more info. Hence my question to you. It is a moot point for me, in any case, because I chose to stay on the meds for now while waiting to see how a couple new procedures turn out.

[Dean F.]

Ah, I see what you're asking… Yes, one thing that you absolutely don't want someone with a fresh fundoplication to do it retch, for the reason you said- popping the stitches and undoing the wrap. Most surgeons only worry about that a lot in the short term, though, when the fixation hasn't had time to scar in. Now, there are studies that have shown that even over many years the wrap never really scars or heals into place fully- if you cut the sutures you can still pull it apart very easily even decades later. But eventually enough scar forms that simply retching isn't a big risk- the scar is just enough to bolster the stitches. (It's not really 'scar', but I don't need to post semantic quibbles, here, do I?) And most people don't spend the rest of their lives in a constant state of retching, so it's a rare exposure anyway. I don't personally know of anyone that keeps fundoplication patients on antiemetics for the rest of their lives or anything like that, if that's what you're asking. I guess that a theoretical case could be made, though I doubt that there is any good data on the issue.

FWIW the Hill has it's place, but the Nissen is the most common by a very, very large margin. "Nissen" is effectively a synonym for "fundoplication" nowadays. Technically, the Hill isn't even a fundoplication- its a gastroplexy. Some surgeons like it if they can't do a Nissen for some reason, but I'd rather do a Toupet, as would most surgeons. (IIRC the Toupet is the second most common fundoplication in the US.) The Hill has far too steep a learning curve, and thus isn't common. Not to mention that it's damned scary blindly throwing sutures that close to the aorta…

[Anonymous]

"Ah, I see what you're asking…"

Thanks for the very informative feedback. As a big believer in second opinions on just about every subject worth discussing, It is exactly what I was looking for.

[Anonymous]

"And most people don't spend the rest of their lives in a constant state of retching, so it's a rare exposure anyway. I don't personally know of anyone that keeps fundoplication patients on antiemetics for the rest of their lives or anything like that, if that's what you're asking."

Again, I should have been clearer. His approach was not to have patients on a routine, prophylactic regimen of antiemetics but, rather, to have them available for quick use should nausea occur. My bad.

Again, thank you, for a most informative response.

[Dean F.]

@ "His approach was not to have patients on a routine, prophylactic regimen of antiemetics but, rather, to have them available for quick use should nausea occur."

As I hinted, one could certainly make a theoretical case for that- it certainly wouldn't be malpractice or such. I severely doubt that there is any class 1 data to support it, but lack of evidence is not evidence of lack, after all…

EDIT— A *very* superficial search of Ovid and PubMed doesn't show anything obvious, though the data might be hidden in there, somewhere. I did see several case studies of fundoplications that failed due to persistent vomiting, though, which doesn't surprise me but again doesn't seem typical. Certainly if someone had chronic vomiting they would need chronic antiemetics after fundoplication.

*** My lawyer insists that I proclaim that I am not giving medical advice over the interwebs. I could not possibly do so without access to all relevant data on a given patient, and examining them myself. ***

[Anonymous]

"*** My lawyer insists that I proclaim that I am not giving medical advice over the interwebs. I could not possibly do so without access to all relevant data on a given patient, and examining them myself. ***

Duly noted and relegated to the circular file, it being a VERY strongly held personal belief that if I should ever have to engage the services of a lawyer, I would have failed profoundly in resolving a situation to the satisfaction of all concerned long before it got to that point, and also breaking my vow to go to my grave with nary a shekel of my financial resources ever having crossed the palm of same. In other words, Cher Acrosome, you have nothing to fear from me. From my perspective, this is purely an intellectual exercise that has expanded my knowledge of a procedure in which I have had a personal interest. For which I thank you once again.

[Eric Blumensaadt]

Both of my daughters are attorneys. (WHERE did I go wrong?)

One is an entertainment attorney, i.e. contracts, and the other a telecom attorney. Both fields are a bit above ambulance chasing, kinda like a sewer worker is a bit above a "honey dipper".

[Anonymous]

"Both of my daughters are attorneys. (WHERE did I go wrong?)"

A cynic would be tempted to ask if you're sure they're yours, but we're above that here. ;0)

[Dean F.]

Even worse- my wife is a lawyer. So I actually CHOSE to associate with one.

That lapse aside, I usually display good judgment. :)

[Eric Blumensaadt]

Tom,

Thanks for the tip. Now to get some DNA tests. I always wondered…

Q. What do female attorneys use for birth control?

A. Their personalities.

Young rebel knights plotting in Shakespeare's Henry V:

Q. "What do we do after we kill the king?"

A. "First we kill all the lawyers."

(We've had some "thread drift" here and I blame it all on Dean. :o)

[Author]

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