Hiatal Hernia and Hypochlorhydria - Week 1

Question 1

What percentage of Americans have a sliding hiatal hernia?

Answer 1

• Over 40% (Merck Manual)
• 15% (Yale)
• 10% in patients under 40, and up to 70% in patients older than 70 (Medscape)

Question 2

What differentiates hiatal hernia (HH) from hiatal hernia syndrome (HHS)?

Answer 2

• In HHS, the proximal stomach may only cause upward pressure against the diaphragmatic hiatus
• In HH, the proximal stomach protrudes through the diaphragmatic hiatus

Question 3

Common symptoms of HH and HHS

Answer 3

• Fatigue
• Mental dullness
• Easy satiety
• Shallow thoracic breathing
• Relatively rapid respiratory rates
• Globus sensation
• Dysphagia
• Chest oppression
• Reflux
• Stitching chest pains
• Regurgitation
• Averse to constriction
• Flatulence
• “Spare tire” bulge just below the inferior margin of the ribs
• Tickling non-productive cough
• Fullness in ears
• Excessive belching
• Anxiety
• Right shoulder pain

Question 4

Diagnosis of HH and HHS

Answer 4

• Imaging would show true herniation

- Reflex points
     > Left of xyphoid (HHS point)
     > 4th ICS mid clavicular
     > 4th ICS mid axillary
     > T 10-11 left paravertebral
- Muscle test

Question 5

Treatment of HH and HHS

Answer 5

- Visceral manipulation
     > Hiatal hernia visceral technique
     > Free the ribs, diaphragm, and occiput
- After manipulations
     > Heel drops
     > Leg raise
     > Knee raise
- Diet
     > Avoid food sensitivities
     > Avoid overeating and large meals
     > Chew food until it becomes liquid (Flecherizing)
     > Avoid stressful discussions or watching TV while eating
- Treat hypochlorhydria (if present)
- Functional breathing and lifting
- Counseling

Question 6

What is the relationship between spinal levels and hiatal hernia syndrome?

Answer 6

• Assess occiput, C3, T10, and T11 for fixations and dysarticulations

Question 7

What are the various options for determining if a patient has hypochlorhydia?

Answer 7

• Heidelberg testing (definitive)
• Gastric string test (screening)
• Riddler’s gastric acid point (functional)
• B/L weakness of pectoralis major clavicular (functional)
• Clinical picture
• HCl challenge
• Labs

Question 8

What is the relationship between hypochlorhydria and gastroparesis?

Answer 8

• Low stomach acid leads to slower digestion of stomach contents, and thus slower emptying of the stomach

Question 9

How could gastroparesis be life-threatening?

Answer 9

• Could cause life-threatening hypoglycemia due to delayed carbohydrate absorption, especially for diabetics
  > If inject short-acting insulin, but then it takes 8-10 hours to digest the carbs, could be life-threatening

Question 10

*What is the explanation for reflux causing symptoms (including heartburn) if a patient has hypochlorhydria?

Answer 10

• Achlorhydric gastric contents and/or bile can cause esophageal pain and/or esophagitis
• Gastroporesis can cause heartburn

Question 11

How do you diagnose EDS-JHT?

Answer 11

• Beighton score of 5 or greater

- Physical exam