The diagnosis and management of hiatus hernia
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6154 (Published 23 October 2014) Cite this as: BMJ 2014;349:g6154
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Dear Madam
Britain is the birthplace of the English language. thebmj has always been a British journal. Its rebranding as an "international" publication cannot deny the origin of the "b" in its title (British), the location of its headquarters (Britain), its owner (the British Medical Association (BMA)) and the vast majority of its print readership (BMA members in Britain).
It is irksome and distracting when reading an otherwise high quality article, such as Roman and Kahrilas' review of hiatus hernia (1), to repeatedly come across words like "esophagus", "anemia" and "anatomic".
Please revert to your previous house style of British English for all submissions.
I beg to remain, Madam, your most obedient servant,
Dr Richard Braithwaite
Consultant Psychiatrist
Isle of Wight NHS Trust
St Mary's Hospital
Newport
Isle of Wight
PO30 5TG
1. Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ 2014;349:g6154J
Competing interests: No competing interests
Dear Editor,
Roman and Kahrilas provide a comprehensive review of the management of hiatus hernia for the non-specialist. However, perhaps the most important current message in Upper GI disease is missing from their article.
Persistent heartburn is not normal and can be an indication of Barrett's oesophagus or oesophageal cancer.
The UK has the worlds highest incidence of oesophageal adenocarcinoma and despite overall cancer survival having doubled over the past 40 years, over the same period mortality for oesophageal adenocarcinoma has risen by 50%. The known risk-factors for oesophageal adenocarcinoma, obesity and GORD, are discussed in detail in this review, but cancer is never mentioned. Worryingly, the authors perpetuate the misconception that endoscopy for GORD should be reserved for patients resistant to medical therapy or for alarm symptoms such as dysphagia, bleeding, weight loss and anaemia. These symptoms are all too often seen with late stage and incurable disease.
The Oesophageal Cancer Westminster Campaign (OCWC) was launched on October 13th and is a coalition of charities, patient representatives, clinicians, individuals and industry partners who aim to improve outcomes for oesophageal cancer patients by influencing parliamentarians and policy-makers in the UK. Oesophageal cancer can be cured if diagnosed at an early stage and that is why the OCWC fully supports the Department of Health's "Be Clear on Cancer" national oesophageal cancer initiative (to be run Jan-Feb 2015) that will focus on the key symptom of persistent heartburn. Perhaps as a profession we could help by getting the message right in our own literature.
If you suffer heartburn most days for 3 weeks of more it could be a sign of cancer - talk to your doctor.
Competing interests: No competing interests
Re: The diagnosis and management of hiatus hernia
Sabine and Peter explain in detail about HIATUS HERNIA management and diagnosis. We came across with few discrepancies in the article and would like to add some clarifications. The author said
“Specialist referral is required if symptomatic treatment is ineffective or there are alarming signs”. We believe that specialist referral is indicative even if the symptomatic treatment is effective as there is still a role for surgical treatment of these patients. And they should be council for it (Ref).
Authors written “clinical indication for endoscopy include symptoms typical of GORD that are refractory to medical treatment, alarming sign or symptoms in patient older than 50 years”. Although there are guidelines (Ref), however it is directed mainly at diagnosing possible cancer and it ignores the fact that many of these patients who has effective medical treatment might be indicated for surgical intervention and hence would need investigations by endoscopy in first instance (REF). , we will include indications for surgery later. Also, the mentioned indications for endoscopy by the authors will miss some patients with cancer whom their symptoms will respond initially to PPI treatment (REF). Similarly cancer of GOJ is increasingly happening in patients younger then 50 years old (REF). We are aware of the likely increased workload for endoscopy, but it is our believe that doing one hundred endoscopies to diagnose only one early cancer is worth doing.
Authors said “sliding hiatus hernia is diagnosed when the apparent separation between squamo columnar junction and constriction formed by hiatus is greater then 2cm.” Though this is one of the criteria of diagnosing hiatus hernia, however it is not an accurate measure particularly in the cases mentioned by authors like Barrett’s oesophagus and inflammation. A more reliable measure of sliding hiatus hernia is to look at the first gastric fold and if it is above the hiatus constriction, its labelled as hiatus hernia.
In relation to surgical treatment of hiatus hernia, authors suggested that it might be worth considering patients with persistent regurgitation, symptoms refractory to medical treatment or intolerance to PPI. Still many patients with GORD who respond to medical treatment should be considered for surgical treatment because PPI on long term reduces acid production which is needed to kill nitrosamine compounds. Prolonged lack of gastric acid might lead to sinister stomach disease(REF). Most authors would agree that patients with GERD symptoms and PPI dependency more then 12 months should be considered for surgical treatment.(REF)
The authors reported that up to 30% of patients resume treatment with PPI within five years of antireflux surgery. From our experience of more than 450 cases of anti-reflex surgery, we believe that this figure of 30% does not reflect the rate of recurrence, which is around 10-15% five years time.(REF) One explanation of 30% rate of PPI resumption is that many patients after antireflux surgery will have some food particles sticking in lower oesophagus above the tightened valve, this ferments and causes burning which mimic heart burn from GERD, and mistaken by clinician as recurrent reflux, hence starting patients on PPI again. This is a false indication of PPI. Whereas all what needed is to give dietary advice taking small well chewed bites.
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Competing interests: No competing interests