A 54 Year Old Man Presents With A Chronic Heartburn

A 54 year old man presents to his primary care physician with the complains of a chronic heartburn that is not responding to medications. He says that he has intermittent symptoms of heartburn for several years but now over the past year the episodes have been more frequent and occasionally painful. He is taking omeprazole which was helping initially but now it seems that his problem is not getting any better. He describes his heartburn as a burning sensation behind the sternum and is worse after eating spicy food or bending over. He denies any episodes of dysphagia, vomiting, blood in stools etc. On examination the patient is an obese man with a normal findings on all the systems.
A Barium Swallow was done as a part of the workup and following was seen:

Air-contrast esophagram shows thick esophageal mucosal folds (arrows) and an ulcer (arrowhead) due to GERD.
Single contrast esophagram shows stricture (arrow) and sliding hiatus hernia

The patient was diagnosed as a case of Sliding Hiatal hernia with secondary GERD

Case Discussion:

Hiatal Hernia: is the herniation of a section of the stomach above the level of the diaphragm

1. Sliding Type: Gastroesophageal junction and stomach are displaced above the diaphragm. (most common 95% cases)
2. Paraesophageal Type: stomach protrudes through the diaphragm, but the gastroesophageal junction remains fixed in the correct location.

Clinical Features:

• Most patients are asymptomatic.
• Some patients present with symptoms of GERD i.e heartburn and does not respond to usual treatments and over the counter antacids.
• Physical examination is non contributory. 

Diagnosis: Chest X ray or barium swallow is useful in detecting the section of the stomach that has herniated through the diaphragm.

Treatment: 

1. Sliding hernias frequently respond to H2 antagonists or proton pump inhibitors.

2. Paraesophageal hernias and sliding hernias that are refractory to medical treatment may be treated with gastropexy or Nissen fundoplication.