Hernia Surgery

Hernia Surgery

Definition

A hernia occurs when part of an internal organ, most often the intestines, protrudes through an abnormal opening or weakening in the wall surrounding a body cavity.

Description

Hernias can occur in many parts of the body, but are most common in the abdominal wall. The abdominal wall is made up of flat sheets of muscle that encase the abdominal organs: the stomach, intestines, liver, kidneys and reproductive organs.

There are five (5) main types of abdominal hernias: (1) Inguinal hernia: a bulge in the groin, (2) Femoral hernia: a bulge in the groin that appears slightly lower than an inguinal hernia, (3) Epigastric (Ventral) hernia: a bulge that appears between the navel and the breastbone, (4) Umbilical (newborn-related) and paraumbilical hernia: a bulge in the navel area, and (5) Incisional hernia: a bulge in the stomach and navel area that is usually caused by prior surgical incision in the area.

A hernia is called reducible if the bulge can be manipulated back into place inside the abdomen.

It is irreducible or incarcerated when the hernia cannot be reduced because adhesions have formed in the hernial sac. It is strangulated if part of the herniated intestine becomes twisted or edematous (swollen), causing serious complications.

Causes and Risk Factors

Hernias can be a result of weak muscles, congenital weakness, heavy work, weight lifting, or even straining during bowel movements.

Procedure

Surgery is the best treatment for a hernia. The physician may advise that a supportive corset or truss be worn until you have the operation, but this is usually only a temporary measure.

Surgeons today perform a variety of techniques to repair hernias. It is important that you discuss with your doctor the type of repair that is right for you. Some of the more common techniques are described below:

The conventional method: This procedure is called herniorrhaphy and involves giving a local or general anesthetic, making a small incision over the hernia, pushing the bulging tissue back into place and removing the hernia sac. The muscles or similar tissues are then sewn together firmly over the hernial orifice.

Typical recovery time to return to normal activities is four to six weeks for hernias resulting from stress or strain. The chance that the hernia will reappear can be as much as 10-15 percent. The surgery is usually performed on an outpatient basis, but sometimes the physician will recommend a one or two day stay.

If the surgery is elective, the patient is usually in good physical condition so there are no specific preoperative measures to follow. The routine preoperative preparation will be provided. If necessary an I.V. (intravenous) line will be started and you will be given analgesics for pain. Many physicians do prescribe perioperative antibiotics prophylactically to reduce the risk of postoperative infection.

The tension-free mesh technique. Under local anesthesia, a small incision is made over the site of the hernia. The bulge is returned to where it belongs and a piece of mesh is placed at the opening of the tissue. This is firmly held in place and the outer incision closed. Over time the muscles and tendons send out fibrous tissue which grows around and through the mesh.

This surgery is also an outpatient procedure, and usually takes less than an hour. After about 45 minutes it is quite common for the patient to be able to get up, go up and down stairs, go for a walk, and even ride an exercise bicycle.

Returning to normal activity depends upon a number of factors. Typically the patient can return to "office" routines in about three days and "physical" occupations within two (2) weeks.

The tension-free mesh/plug technique: This technique is performed under local anesthetic and through a small incision the surgeon inserts a mesh/plug combination. The tapered shape of the plug fills the hole like a cork in a bottle. A second piece of flat mesh is placed over the plug to help prevent future hernias at the same site. Like the tension-free mesh only technique, the tissues will grow around and through the mesh.

The laparoscopic method: The procedure requires only two small punctures of the abdomen at a site remote from the defect. Then the surgeon insufflates the abdomen with carbon dioxide or nitrous oxide, creating a balloon-like space in which to work. Then he inserts the laparoscope (a tube with a small camera on the end) through the navel by using a trocar (an instrument that withdraws fluid) and cannula (a tube). The surgeon locates the hernia and inserts a stapling device through a second cannula. The device has forceps to grip and immobilize the hernia orifice and a stapling mechanism to seal the orifice. After complete closure with as many staples as required, the instruments are removed and the abdominal puncture wounds closed with one or two sutures.

This procedure can be done on an outpatient basis, in contrast with the traditional operation which required an hour of operating time, one or two day in-patient stay, and six weeks until full recovery.

Questions to Ask Your Doctor

What type of hernia is it and is surgery recommended?

How new is this surgery?

Is this the accepted treatment for this diagnosis?

What kind of anesthetic will be used? Are there alternatives?

What are the risks or complications to this surgery?

What is the success rate and will the surgery take care of the problem completely?

What are the likely consequences and alternatives if surgery is delayed or declined?

Are there alternatives to the proposed surgery and what are the risks and benefits of each?

Will work be missed?

What precautions should be followed after the surgery?

Hernias cause pain and reduce general mobility. They never cure themselves, even though some can be cured (at least temporarily) by external manual manipulation. Depending on the nature of the protruding organ and the solidity of the structure through which it is protruding, a hernia may cause complications that are medically dangerous.

One major danger of a hernia is that if bowel is contained within the protruding loop it may hinder or stop the flow through the intestine (occlusion). More serious still, if the loop itself becomes twisted outside its containing structure, or compressed at the point where it breaks through that structure (a strangulated hernia), the blood supply to the loop will also cease and the entire hernia will undergo tissue death (necrosis). This requires immediate emergency surgery.

Early on, the hernia may be reducible - the protruding structures can be pushed back gently into their normal places. If those structures, however, cannot be returned to their normal locations through manipulation, the hernia is said to be irreducible, or incarcerated.

Treatment

For small, nonstrangulated hernias and nonincarcerated hernias, various supports and trusses may offer temporary, symptomatic relief. However, the best treatment is herniorrhaphy (surgical closure or repair of the muscle wall through which the hernia protrudes).

When the weakened area is very large, some strong synthetic material may be sewn over the defect to reinforce the weak area. Postoperative care involves protecting the patient from respiratory infections that might cause coughing or sneezing, which would strain the suture line. Recovery is usually quick and complete.

Questions to Ask Your Doctor

What is the success rate and will the surgery take care of the problem completely?

What are the likely consequences and alternatives if surgery is delayed or declined?

Are there alternatives to the proposed surgery and what are the risks and benefits of each?

Hiatal hernias are common, especially among people who are overweight. In most instances, a hiatal hernia causes no symptoms and is of no significance. You may not even know that you have one, unless your doctor discovers it after a routine X-ray.

On the other hand, you may be all too familiar with one of its most common symptoms: gastresophageal reflux (see the health profile Gastroesophageal Reflux Disease - GERD). This is a burning sensation that radiates upward from your lower chest or upper abdomen, or an unpleasant regurgitation that occurs when you lie down or bend over.

Doctors believe a hiatal hernia may contribute to reflux (backward flow) of stomach contents. A sphincter (ring-like muscle) separates your stomach from your esophagus. Think of this muscle as a rubber band that constricts to form a one-way valve, preventing stomach contents from refluxing. As the pressure in your stomach increases, it can overcome the pressure exerted by the sphincter - much like stretching a rubber band - allowing the reflux to occur.

Whether or not you need to see a doctor for a hiatal hernia depends on the severity of your symptoms. Occasional reflux of stomach contents commonly occurs in almost everyone, however, a hiatal hernia can increase the amount or frequency of reflux, making it more likely for you to have heartburn.

If you smoke, are overweight or eat certain foods that contribute to acid backup, your symptoms may be worse. Frequent reflux of stomach contents can lead to esophagitis, an inflammation of the lining of the esophagus. When severe, esophagitis can cause a stricture (narrowing) of the esophagus. A stricture makes swallowing of food difficult or painful.

Causes and Risk Factors

The most frequent cause of hiatal hernia is an increased pressure in the abdominal cavity produced by coughing, vomiting, straining at stool or sudden physical exertion. Pregnancy, obesity or excess fluid in the abdomen also contribute to this condition.

If you have a hiatal hernia, your doctor will probably suggest one of these three approaches to manage your condition:

No treatment - if you do not have any symptoms from a hiatal hernia, and most people do not, you probably do not need to do anything about it.

A combination of lifestyle changes and medications - if you have recurrent gastroesophageal reflux, eliminating coffee, alcohol and smoking, combined with weight reduction if you are overweight, may do a great deal to relieve the heartburn and prevent esophagitis.

The great majority of patients can be managed by a conservative program. Every effort must be made to enlist the aid of gravity in preventing reflux at night. The patient should not lie down after meals and should not eat a late meal before bedtime. The head of the patient's bed should be elevated on six inch blocks; attempting to sleep propped up on pillows almost never succeeds.

Also, antacids or antacid combinations containing alginic acid can help neutralize stomach acid. If these changes do not help, your doctor may prescribe drugs such as cimetidine, ranitidine or omeprazole to reduce stomach acid secretion.

Surgery - when severe symptoms of reflux persist despite the combination of lifestyle changes and medications, or if the complications such as stricture, chronic bleeding or obstruction develop, surgery may be necessary. The surgeon's goal is to "rebuild" the esophageal sphincter and repair the hernia.

There are two types of esophageal hiatal hernia: paraesophageal and sliding. Symptoms from an uncomplicated paraesophageal hernia usually develop in adult life and may consist of a sense of pressure in the lower chest after eating and occasionally palpitations, due to cardiac arrhythmias. All of these are pressure phenomena, caused by the enlargement of the herniated gastric pouch when food displaces the fundic (stomach’s) air bubble.

Since complications are frequent in paraesophageal hiatal hernias, even in the absence of symptoms, operative repair is indicated in most cases. The usual method is to return the herniated stomach to the abdomen and affix it with sutures to the posterior rectus sheath (anterior gastroplexy). The enlarged hiatus is closed snugly around the gastroesophageal junction with interrupted sutures. It is unnecessary to excise (cut out) the hernia sac. The results of surgical management are generally excellent.

Most patients (80 percent) with clinically significant reflux have a sliding hiatal hernia. In these patients, the cardioesophageal junction and the fundus of the stomach are displaced upward into the posterior mediastinum, exposing the lower esophageal sphincter to intrathoracic pressure. At least half of all sliding hiatal hernias are asymptomatic and require no treatment.

An inguinal hernia, or a groin hernia, is a protrusion (lump) of the small intestine or fatty tissue into the groin through a weakness or tear in the abdominal wall.

Description

In a man, an inguinal hernia develops in the region where the spermatic cord and blood vessels to the testicles pass out of the abdominal cavity and into the scrotum. The area where these pass through is called the inguinal canal.

In a woman, an inguinal hernia develops where the connective tissue binding the uterus exits from the abdomen to join with the tissue surrounding the vaginal opening.

Inguinal hernias are usually caused by a congenital defect which occurs as a weakness in the inguinal canal manifesting after injury, pregnancy or aging. Inguinal hernias may appear following surgery or after heavy lifting, birthing a child, exercising, persistent coughing, straining while urinating or defecating or by gaining a lot of weight.

Symptoms

Frequently hernias produce no symptoms. However, some people may experience the following symptoms:

If the lump is large, the doctor can see an obvious swelling or lump in the groin. If the hernia is small the doctor will examine the groin area for a bulge in the affected area.

Treatment

If the hernia is causing only slight discomfort and can be pushed back (reductible hernia), the doctor will recommend that the patient wear a supportive garment called a truss. A truss is a device that puts pressure on the hernia and holds it in.

Hernias that are painful and can't be pushed back (incarcenated or strangulated hernia) are treated surgically. There are two surgically procedures available for the treatment of inguinal hernias - open surgery or laparoscopy.

Open surgery is the most common type of treatment, accounting for 95 percent of inguinal repairs. This procedure is done under local anesthesia and requires a 4- to 6-inch incision in the groin. The doctor then pushes the herniated tissue back into place and sutures the opening shut. Sometimes a small piece of synthetic material is placed over the gap to serve as a scaffolding on which scar tissue will grow. Full recovery time takes 4 to 6 weeks.

Laparoscopy is done under general anesthesia and involves three small incisions (1/2 inch or less) in the abdomen which in then inflated with carbon dioxide. A laparoscope (a fiber-optic narrow tube with a light on the end) and other instruments are inserted through the incisions. Using a monitor the surgeon pushes the herniated tissue back into place and staples a patch over the opening. Full recovery takes a week or less.

Although there is not much a person can do to totally prevent a hernia many experts suggest:

During the growth of the fetus, the intestines grow more rapidly than the abdominal cavity. For a period, a portion of the intestines of the unborn child usually lies outside the abdomen in a sac within the umbilical cord. Normally, the intestines return to the abdomen, and the defect is closed by the time of birth.

Occasionally, the abdominal wall does not close solidly, and umbilical hernia results. This defect is more likely to be seen in premature infants and in girls than boys.

The defect in the abdominal wall usually closes by itself. Coughing, crying, and straining temporarily cause the sac to enlarge, but the hernia never bursts and digestion is not affected. When the baby cries, a small part of the intestine is pushed through the umbilical ring and makes the navel puff out somewhat. This is the umbilical hernia.

When the ring is small, the protrusion of the hernia is never much larger than a pea and the ring is likely to close over in a few weeks or months. When the ring is large, it may take months or even years to close and the protrusion may be larger than a cherry.

It used to be thought that the closing of the umbilical ring could be hastened by putting a tight strap of adhesive across the navel to keep it from protruding. It is now believed that strapping makes no difference. It is much easier not to bother with the adhesive, which always became soiled, soon loosened, and left raw places on the skin.

There is little need to worry about the protrusion of the hernia. It rarely causes any trouble, as other hernias do. There is no need to keep the baby from crying.

In the well-padded, older child or adult, the fat over the abdomen is thick enough to make the navel appear to be at the bottom of a hole. This is rarely the case in the first 2 or 3 years of life. The folds of the skin of the navel (looking something like a rosebud) stand right out on the full abdomen. This prominence of the skin folds on the navel should not be confused with a hernia. A hernia can be felt underneath the skin folds, like a small, soft balloon. A hernia makes the navel stick out farther than it would otherwise.

If an umbilical hernia is still large after a few years and showing no decrease, surgical repair is sometimes recommended.

Umbilical hernia should be distinguished from omphalocele, in which the intestines protrude directly into the umbilical cord and are covered only by a thin membrane. Omphalocele is a surgical emergency that must be treated immediately after birth.

What is the procedure of the surgery? Are there any complications to this surgery?

What are the possibilities the hernia will protrude again? Are there any measures to prevent the reoccurrence?

Enterocele is a hernia of the intestine through the vagina. Rectocele is a hernia of the rectum through the vagina.

Causes and Risk Factors

Stretching, weakening, and tearing of the fascia (a fibrous membrane) and muscles of the female pelvic floor are often caused by the trauma from the descent of the baby's head through the pelvic diaphragm.

Additionally, the loss of estrogen (due to age), vaginal deliveries (perhaps breech extractions, forceps rotations), strenuous work and inadequate episiotomy (surgical incision of the vulva) can lead to these problems. Multiple births, large pelvic tumors, marked obesity, ascites (accumulation of serous fluid in the peritoneal cavity), and lifelong chronic constipation (rectocele-related only) are other elements that may produce weakening of the musculofascial (muscle and membrane) supports. This leads to the formation of rectocele and enterocele.

Diagnosis is made by a pelvic and a rectovaginal exam. The bulges (hernias) are felt by the doctor when the woman holds her breath and "bears down" during the pelvic examination. During the rectovaginal examination the woman is asked to stand and squat slightly while straining.

Treatment

With complete eversion of the vagina by the enterocele, ulcerations, edema, and fibrosis of the vaginal walls may occur to such a degree that the prolapsing mass cannot be reduced.

Rest in bed (with the foot of the bed elevated) and wet packs applied to the vagina will reduce edema and allow replacement of the vagina, and vaginal packing can be used to maintain reduction until local conditions permit operative correction (surgery).

Inasmuch as symptomatic enterocele almost always is associated with other forms of musculofascial weakness (rectocele, cystocele, uterine prolapse), a transvaginal operation provides the best route of repair and offers the greatest likelihood of permanent correction of the enterocele.

Operative correction by any means, whether by the vaginal or the abdominal route, should restore the vaginal axis to normal. In general, enterocele repair is performed as part of a comprehensive vaginal or abdominal repair of the pelvic floor relaxation (as with rectocele and cystocele).

Many people with large enteroceles are elderly; others are grossly obese. While the person's general health is being improved, the prolapsing vaginal hernia can be reduced with a pessary if it can be retained. Occasionally, packing the reduced vagina with cotton tampons or gauze impregnated with medicaments is more effective than using a pessary.

If immediate operative correction is not essential, a rigorous program of weight reduction for several months may be extremely beneficial for the very obese patient and may increase her chance of eventually obtaining a successful repair.

If the woman is postmenopausal, with mild to moderate symptoms, the doctor may suggest estrogen therapy. Estrogen hormone vaginal cream or oral hormone treatment may help restore a more normal, resilient vaginal and urethral lining as well as improve bladder control.

Simple exercises, called Kegel exercises, are also suggested to strengthened the muscular supports for the vagina and urethra, improve bladder control and experience effective penile stimulation during intercourse. "Kegels" involve contracting the muscle of the urethra, vagina and rectum for a set period of time and then relaxing them.

A vaginal pessary is another non-operative alternative. A pessary is a firm latex device, something like a contraceptive diaphragm without the rubber dome, placed inside the vagina to provide additional support to the bladder and uterus.

If bladder or bowel problems are severe and the non-operative treatments do not alleviate the symptoms, the doctor will recommend a vaginal hysterectomy (removal of the uterus and cervix through an incision inside the vagina) with posterior colporrhaphy (suturing of the vagina).

With better obstetric care, better use of episiotomies to prevent tearing of the pelvic muscles, immediate repair of all tears, and the trend toward fewer pregnancies and births per woman, fewer women should require vaginal wall repairs late in life.

Neglected, obstructed labor and traumatic delivery, which weaken uterovaginal supports, should be avoided. Perineal exercises practiced after delivery help to prevent relaxation. Factors that increase intrabdominal pressure (obesity, chronic cough, straining, ascites, large pelvic tumors) should be corrected promptly.

Questions to Ask Your Doctor

This is a ring of tissue in the lower esophagus located at or near the border of the lower esophageal sphincter. It is also known as a lower esophageal ring. Being confined to the mucosa, it differs from an inflammatory (peptic) stricture, which involves all layers of the esophagus.

Causes and Risk Factors

Most are over 20 millimeters in diameter and are asymptomatic. Solid food dysphagia (difficulty swallowing solid food) most often occurs with rings less than 13 mm in diameter. The dysphagia is usually intermittent and is not progressive.

Large, poorly digested food such as steak are most likely to cause problems. Drinking extra liquids or regurgitation may relieve the obstruction.

Lower esophageal rings may be diagnosed clinically and confirmed by barium swallow (a radiological study to assess swallowing) and upper endoscopy (using a tube to enter the mouth in order to view the esophagus and stomach).

The majority of symptomatic patients can be treated permanently with the passage of large (17 to 20 millimeter) dilators, which disrupt the mucosal ring. Single dilations of symptomatic lower esophageal rings are safe, easily performed, and well tolerated. Recurrences can be successfully treated by repeated dilations.
Questions to Ask Your Doctor

The esophagus is the tubelike structure that connects the mouth to the stomach. When you swallow, food and beverages are moved down the esophagus by wavelike involuntary muscle contractions to the stomach's entrance. At that point, the muscle of the LES relaxes (opens) to let the food pass into the stomach and quickly closes again.

The backwash of stomach contents into the esophagus, commonly called reflux, occurs when the LES muscle is very weak or, more commonly, when it inappropriately relaxes causing heartburn. Heartburn is the burning sensation in the throat or chest caused by the backwash of the stomach contents (usually acidic).

GERD is extremely common, with 20 percent of all adults reporting at least weekly episodes of heartburn. Up to 10 percent of all adults complain of daily symptoms. Most patients have a mild disease and few develop esophageal mucosal damage (reflux esophagitis) or more severe problems.

Causes and Risk Factors

Some doctors believe that a hiatal hernia may weaken the LES and cause reflux. A hiatal hernia is a defect in the diaphragm that permits a portion of the stomach to pass through the diaphragm's opening into the chest.

Dietary and lifestyle choices may also contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods and coffee or alcoholic beverages, may weaken the LES, causing reflux. Additionally, studies have shown that cigarette smoking, obesity, pregnancy and asthma may also be associated with GERD.

The most common symptom of GERD is heartburn. Heartburn most often occurs 30 to 60 minutes after meals. The heartburn is usually intensified by eating, lying down, bending over or exercising. Patients often report relief from taking antacids or baking soda.

Additional, atypical symptoms may include regurgitation of acidic materials, chest pain, asthma, chronic cough, chronic bronchitis, chronic sore throat, morning hoarseness, swallowing difficulty, bloating, belching, nausea and weight loss. Some patients with severe esophagitis may be almost asymptomatic.

Medical history is most important, because physical examination and laboratory tests are often normal in uncomplicated GERD. Further investigation may include upper endoscopy with biopsy (viewing the esophagus and stomach through a narrow tube and sampling a small piece of tissue) and rarely, barium studies or pH monitoring (to document abnormal acid exposure in the esophagus).

For patients with mild GERD, doctors recommend simple lifestyle changes, such as quitting smoking or losing weight, dietary changes, and taking over-the-counter (OTC) antacids.

Physicians suggest eating smaller meals and avoiding acidic foods (such as tomato products, citrus fruits, spices and coffee), fatty foods, peppermint, chocolate and alcohol. Most importantly, it is recommended to avoid eating three (3) hours prior to bedtime or to lying down.

Elevating the head of the bed on 6-inch blocks may reduce heartburn by allowing the effect of gravity to minimize reflux of stomach contents into the esophagus at night.

Quitting smoking may also reduce the symptoms of GERD. Additionally, refrain from wearing tight clothes that put pressure on the abdomen.

Antacids may help neutralize the stomach acid and stop heartburn. Antacids have long been a mainstay of treatment of gastroesophageal reflux. These agents not only buffer acidic gastric contents, but may also lower esophageal sphincter pressure by stimulating gastrin release in response to alkalization in the stomach. Alginate antacid (Gaviscon Liquid), Maalox TC, Mylanta II and other medications, may provide relief of occasional heartburn.

When patients with mild to moderate symptoms of GERD fail to improve with lifestyle changes and antacids, the next step is to try other medications. Doctors may suggest a Histamine2 (H2) receptor antagonist, such as cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid) or nizatidine (Axid), each if which has a moderate ability to suppress acid.

Another option is to prescribe prokinetic drugs, such as cisapride (Propulsid), that helps in contracting the LES, clearing the esophagus and enhancing gastric emptying.

If GERD is considered severe, the doctor may prescribe proton pump inhibitors, such as omeprazole and lansoprazole.

If these behavior modifications and drug therapies do not work, the doctor may recommend further testing and ultimately, surgery.

Surgery may be warranted in patients whose medical therapy has failed, who have experienced complications or side effects with the drug treatment(s), who have had relapses of GERD, or who have been diagnosed with Barrett's esophagus, esophageal stricture, esophageal ulcers, esophagel bleeding or a hiatal hernia.

There are two types of anti-reflux surgeries: open and laparoscopic. Laparoscopic surgery (done via tiny incisions in the abdomen) is the procedure of choice due to the reduced post-surgical recovery time. The most common laparoscopic anti-reflux surgery is called laparoscopic Nissen fundoplication. In this procedure, surgeons rebuild the upper end of the stomach into a high-pressure zone, strong enough to prevent acid juices from rising into the esophagus, but not so strong that food cannot enter the stomach.

What tests need to be done to diagnose the condition? How are these tests performed?

Esophagitis is the inflammation of the esophagus (the muscular tube that carries food from the throat to the stomach).

Description

The two principal types of esophagitis are corrosive esophagitis and reflux esophagitis.

Corrosive esophagitis is caused by swallowing of caustic chemicals (acid or lye) accidentally or in a suicide attempt. The severity of the inflammation depends on the type, amount, and concentration of caustic chemical swallowed.

Immediately after swallowing such a chemical, there is severe pain and edema in the throat and mouth. Antidotes are of limited value and gastric lavage must be avoided as this may only increase the damage. Treatment consists mainly of reducing pain and providing nursing care until the esophagus heals.

Reflux esophagitis or gastroesophageal reflux disorder (GERD) is a very common condition. The cause is poor functioning of the musculature of the lower esophageal segment, which permits reflux of the stomach's contents.
Causes and Risk Factors

Chemicals especially likely to cause very severe corrosive esophagitis include cleaning or disinfectant solutions.

Factors that contribute to the development of reflux esophagitis include the caustic nature of the refluxate, the inability to clear the refluxate from the esophagus, the volume of gastric contents, and local mucosal protective functions.

Poor lower esophageal segment functioning may be associated with a hiatal hernia, in which the top part of the stomach slides back and forth between the chest and the abdomen. Symptoms may be worsened by alcohol, smoking, sedentary lifestyle and obesity.

The main symptom of reflux esophagitis is heartburn, with or without regurgitation of gastric contents into the mouth, which worsens on bending over. Complications of GERD include esophagitis and possibly massive but limited hemorrhage.

Treatment of corrosive esophagitis involves reducing pain and making the patient comfortable. Gastric lavage is to be avoided in that it may worsen the condition.

Development of a severe esophageal stricture may require dilatation and perhaps surgery. Uncomplicated GERD may be tolerated for many years with good response to medical therapy.

Would antacids help? Will you prescribe an H2 agonist (Histamine-2 receptor agonist) such as cimetidine. What can be done to minimize the discomfort?

Cancer of the stomach - also called gastric cancer or gastric carcinoma - is a treatable disease that can often be cured when it is found and treated at a local stage.

Description

The most common type arises in the glandular tissue lining the stomach. These tumors are called adenocarcinomas and account for over 95 percent of all stomach tumors.

One particular form of this cell type, unusual in the U.S. but more common in Japan, is the superficial spreading adenocarcinoma that essentially replaces the lining (mucosa) of the stomach with sheets of malignant cells.

Another subtype is scirrhous carcinoma (linitis plastica), a poorly differentiated mixture of mucin-producing carcinoma cells that infiltrates the muscle wall and turns it into rigid, leatherlike scar tissue that cannot stretch or move during the normal digestive process (peristalsis).

Occasionally a cancer may develop in lymph tissue (gastric lymphoma) or from the smooth muscles of the stomach wall (leiomyosarcoma). Carcinoids and plasma-cytomas also can develop in the stomach.

The disease can spread directly through the stomach wall into adjacent organs and through the lymph system to nodes in the abdomen, the left side of the neck and the left armpit.

Metastases through the bloodstream can spread to the liver, lungs, bone and brain. Metastases are also found in the lining of the abdominal cavity (peritoneum) and around the rectum.

Those at significantly higher risk are those aged between 50 and 59; workers in various industries (coal mining, nickel refining, rubber and timber processing); workers exposed to asbestos fibers; people with pernicious anemia who are 5 to 10 percent more likely to develop gastric cancer; and persons whose diet contains smoked, highly salted and barbecued foods.

Japanese immigrants have a decreased incidence of this cancer when they adopt an American diet and lifestyle, with a tenfold drop after two generations.

The symptoms of stomach cancer are similar to the symptoms of a hiatal hernia or peptic ulcer, namely a vague pain aggravated by food, nausea, heartburn and indigestion. These symptoms are often thought to be due to the stress of psychosomatic illness and are treated with antacids or H-2 blockers. Unfortunately, the temporary relief this treatment brings often delays the tests that could diagnose cancer.

Loss of appetite, feelings of fullness after even a small meal, and weight loss are common - upper abdominal pain, vomiting after meals and weight loss are seen in 80 to 90 percent of cases.

There also may be mild anemia, weakness, gastrointestinal bleeding and vomiting of blood. Both vomiting blood and rectal bleeding are seen in peptic ulcer disease, esophageal varices (varicose veins in the esophagus that grow and burst, a disease common in drinkers), and occasionally leiomyosarcomas.

Gastric cancers often seem to be benign ulcers, which are like pits in the stomach lining. Larger ulcers - more than 3/4 in. (2cm) in diameter - that have borders raised above the level of the surrounding stomach are more likely to be malignant.

Physical Examination. There are few specific findings on a physical examination, and they generally indicate an advanced tumor. Some findings might be:

Stomach cancer is a somewhat treatable disease, with over half the patients with early stage disease being curable. Early-stage disease accounts for only 10 to 20 percent of all cases diagnosed in the U.S.. In early-stage disease over 50 percent are curable.

Five-year survival for more advanced cancers range from around 20 percent for those with regional disease to almost nil for those with distant metastases. Treatment for metastatic cancer can relieve symptoms and sometimes prolong survival, but long remissions are not common.

The ideal treatment is radical surgery, meaning that most or all of the stomach is removed (subtotal or total gastrectomy), along with the surrounding lymph nodes. Radical surgery is the only treatment that can lead to a cure, though lesser surgical procedures can play a significant role in therapy designed to relieve symptoms.

Radiation and chemotherapy are also treatment options. Neither has been shown to improve the outlook for those with advanced tumors, generally, although some patients with responsive tumors may benefit.

Spermatoceles are epididymal cysts so named because of the frequent finding of sperm in the cyst fluid. They are the most common cystic condition encountered within the scrotum.

Spermatoceles are usually found at the head of the epididymis, adjacent or posterior to the superior pole of the testicle.

Spermatoceles vary in size from several millimeters to many centimeters in diameter and may be single or multiple, unilateral or bilateral.

The cause of spermatoceles remains controversial. It is believed that they may originate as a diverticulum from the tubules found in the head of the epididymis. With spermatogenesis over time, the diverticulum increases in size, ultimately producing a spermatocele.

Spermatoceles also are believed to form as a result of infection (epididymitis) or trauma. If any portion of the epididymis becomes obstructed by scar formation, a spermatocele can form.

Spermatoceles typically present as incidental scrotal masses found on routine physical examination. They may be discovered by an individual during self-inspection of his scrotum or testicles, or when large, by palpation by his partner.

Spermatoceles are asymptomatic except when large, and then may be associated with testicular discomfort.

The differential diagnosis of a painless scrotal mass includes spermatocele, hydrocele, hernia, varicocele, tuberculosis of the epididymis, and tumors of the testicle or epididymis.

Acute inflammatory processes involving the epididymis or testicle such as epididymitis, orchitis, or testicular torsion, are associated with a high degree of pain and should not be confused with spermatocele.

Diagnosis of spermatocele is best made on physical examination. The finding of a cystic, painless mass at the head of the epididymis that transilluminates and can be definitely differentiated from the testicle is generally sufficient to confirm the diagnosis.

If uncertainty exists, ultrasonography of the scrotum will confirm the diagnosis.

Small cysts of the epididymis are best left alone, as are larger cysts when asymptomatic. Only when the cysts are associated with discomfort and are enlarging in size, or when the patient wants the spermatocele removed, should surgical intervention be considered.

The patient should be made aware that spermatocelectomy will not improve fertility and should not be performed for this reason. It also is possible that pain may persist after spermatocele removal.

Once it has been decided to proceed with spermatocelectomy, the procedure can be performed on an outpatient basis. The technique is performed easily under local or general anesthesia.

Lumbar muscle spasms are involuntary contractions of the muscles of the lumbar region of the back (the lower back).

Description

The back's muscles and any of the ligaments can be injured or irritated. What causes trouble may be a sudden movement in the heat of a tennis match or a game of touch football, or a fall, twist, or sudden muscle contraction to avoid a fall. Sudden pain usually follows a clear-cut injury, though there may be a delay of hours or even a day or two. Specific movements tend to aggravate pain, and muscle injury may bring with it a palpable muscle spasm.

Muscle spasms can also happen without muscle injury, as a reflex phenomenon from irritated deeper structures, including torn ligaments, infections, tumors, or chronic disc irritation, or herniation. The way you move, your posture, and other tests permit the doctor to separate a primary muscle spasm from that caused by some underlying disease.

Many so-called disc abnormalities are actually a combination of the aging process and cause no symptoms. Although pain from an abnormal disc may come on suddenly, the process by which it was caused generally occurs gradually, sometimes taking years to develop.

Discs begin to dry up, or become desiccated, starting in young adulthood. The most likely places for changes to begin are the discs at the junctures called L4-L5. No one knows exactly why these two discs are the most vulnerable, but one speculation is that it is due to the sheer stress accentuated by the presence of the lumbar curve.

As a result of this process of wearing out or degenerating, the disc slowly loses its ability to bounce back. In the first stage of anatomic abnormality, the soft interior (nucleus pulposus) of the disc bulges outward. This causes pressure on the nerve, which irritates it. If stenosis, or narrowing, of the spinal canal is also present, the likelihood of pain increases.

While some people with a stage-one bulge may never appear in the doctor's office complaining of back pain, the classic stage-one patient comes to the doctor because of sudden, acute onset of pain. The reason for the pain is not so much the bulging disc itself but the fact that the back muscles are in spasm, usually on one side of the back. This is why a person with this kind of backache characteristically walks tilted over sideways and with great difficulty.

The cause of the muscle spasm lies in the fact that the bulging disc is pressing against the ligament that holds it in place. Since this ligament contains nerves, the result is pain. Because of the initial pain, the back muscles go into spasm as part of the body's effort to immobilize the painful area. Rather than improving matters, the result is more pain.

After several episodes of this type, the bulge may become what is called herniated, indicating that the problem has worsened involving the sciatic nerve and spinal nerve root compression.

Severe pain and palpable tension in the muscles of the lower back.

Diagnosis

The old standby, aspirin, is extremely useful. It not only relieves pain but reduces inflammation, and it is one of the safest drugs on the market.

The nonsteroidal anti-inflammatory drugs (NSAIDS) are also frequently prescribed. They work in a similar fashion to aspirin and may be more convenient, because some need to be taken only once or twice a day. Some of these drugs are now available over-the-counter.

Cortisone and other steroid drugs are occasionally used for a short period to reduce pain and inflammation. They can be quite effective in relieving the symptoms of acute back pain, but they can also cause serious side effects and are not useful as a long-term approach. When pain is more severe, more potent painkillers may be prescribed, again for a brief periods.

Narcotic analgesics, such as Percodan and Demerol, are very rarely needed and usually not prescribed for more than a few days at a time. There is a debate about the role of muscle relaxants and tranquilizers in treating back pain. It is not clear whether they are any more effective than NSAIDS.

Distress from heartburn is common after a meal of fat-laden or acidic foods, after taking aspirin, drinking alcohol, smoking, or eating chocolate. Obesity, pregnancy, emotional turmoil, and tension can also trigger heartburn. In general, there is no cause for concern with frequent heartburn.

The ads for antacid pills like Tums, Gelusil and Maalox call heartburn "acid indigestion," but actually the problem is more complicated than that. In the vast majority of cases, heartburn is a symptom of gastroesophageal reflux (GER) in that stomach fluids containing acid and digestive enzymes back up past the valvelike sphincter that separates the stomach from the esophagus, causing pain.

OTC drugs that neutralize stomach acid are, for most people, the first line of defense against heartburn. Antacids come in tablet, liquid, or foam, and in regular and extra-strength formulations.

The active agents in antacid compounds usually consist of one or more of the following ingredients: magnesium, aluminum hydroxide. sodium bicarbonate, or the centuries-old standby, calcium carbonate.

Antacids should bring relief almost instantaneously. These active compounds buffer the accumulated acid in the stomach. This helps reduce or eliminate the burn that is felt in the esophagus. Antacids do not reduce any further acid buildup or eradicate feelings of fullness in the stomach.

A recommended dose one to three hours after eating should provide varying degrees of relief. If a single dose does not work, the problem may be more severe, and a doctor should be called.

What actually determines the overall effectiveness of an antacid depends on what and how much you ate or drank, and the overall state of your gastrointestinal tract.

In addition, if you have high blood pressure or are on a sodium-restricted diet, do not take antacids containing sodium bicarbonate because of its high sodium content. If you have kidney problems, avoid antacids with magnesium or aluminum.

Also, if you are bothered by kidney stones, do not take calcium carbonate antacids because the calcium can accelerate the problem. Calcium carbonate antacids will initially quell acid buildup, but because they contain calcium, this antacid will soon cause an increase in stomach acid.

Contrary to popular belief, milk is not a recommended antidote to heartburn. A glass of milk does provide immediate relief as it goes down, but milk contains calcium and protein, and these eventually stimulate even more acid production in the stomach. This can cause a more severe heartburn that can return in as little as a half an hour.

In some cases, antacids and certain drugs do not mix. Tetracycline, indomethacin, and buffered and nonbuffered aspirin, iron supplements, digoxin, quinidine, Valium, and corticosteroids can adversely mix with acids in the stomach, causing problems that are more serious than heartburn.

Relief from heartburn has been provided for more than a century by antacids that include such familiar brand names as Tums, Rolaids, Maalox, and Mylanta. These antacids, which bring relief in minutes, work by neutralizing the stomach acid that causes heartburn. But because the stomach continues to produce acid, they remain effective only for a few hours.

Beginning in the late 1970s, pharmaceutical companies started offering drugs such as Zantac, Tagamet, Pepcid and Axid, available only by prescription for those with serious heartburn or ulcers. Now these are available over the counter.

What separates the new OTC preparations from antacids is that antacids only neutralize the acid which continues to migrate upward from the stomach. Acid blockers, like Tagamet and Pepcid, on the other hand, go to the root of the problem by suppressing the production of acid in cells lining the interior of the stomach without interfering with normal digestion.

These cells normally produce acid when a form of histamine called H2 "docks" with receptors in the cell walls, much like a key fitting within a lock. But acid blockers, called H2 antagonists, prevent that production by seeking out and fitting snugly into the stomach cell receptors, denying access to H2. Depending on the size of the drug dosage, acid production can be curtailed for as long as 1 to 2 hours.

As for side effects, several studies have shown that both antacids and blockers may mask the symptoms of bleeding ulcers among people with rheumatoid arthritis. These patients often take the pills thinking that they will relieve bleeding that can occur with high doses of rheumatoid arthritis drugs like ibuprofen. While neither H2 antagonists nor antacids cause bleeding they may keep those with ulcers from recognizing the need to seek help.

H2 blockers still have fewer side effects than antacids. Meanwhile, calcium-based antacids like Tums and Rolaids can occasionally contribute to kidney stones. The aluminum- and magnesium-based ones like Mylanta and Maalox can sometimes be dangerous for people with kidney problems. On the whole, the risk-benefit profile for H2 blockers is excellent, and they represent an advance over what was previously available.