Ep 213 – Hiatal Hernia: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

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0:01:38.6 RW: Hi, and welcome to I Have Client Who... Pathology Conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Warner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice. And sometimes, as we have all learned, that is harder than it looks.

0:02:25.3 RW: Today's "I have a client who" story comes out of a conversation I had with one of the people in this field that I most respect, Nancy Dail, owner and director of Downeast School of Massage in Waldoboro, Maine. Nancy and I were chatting about an alliance for massage therapy education event recently, and she let drop that she is waiting for surgery for a very severe hiatal hernia. Well, let me give you a hint. Never tell a pathology teacher about your health, unless you wanna spend the next half hour shelling out details. Nancy was generous enough to let me share some of her details in I have a client who, because hiatal hernias are very common and they're usually not a big deal, but in some cases, like Nancy's, they can become a very serious problem, especially if you need surgery during a pandemic. Her procedure has been scheduled and then delayed three times so far because of COVID populations in her local hospital. So in this case, we don't really have a client. We have a massage therapist and a teacher who has been deeply affected by this very common problem, and it has impacted her ability to do her many jobs.

0:03:35.3 RW: So we will take a look at hiatal hernias in general, and what people may do to treat them, and then we'll talk a little bit about Nancy's situation, and we will wrap up with some ideas about where or if massage therapy might safely intersect with someone whose stomach is sliding up between their lungs. Sounds delightful, right? So, hiatal hernias. You will recall that the diaphragm, a word which comes from the Greek for "partition," is a parachute-shaped muscle that separates the thoracic from the abdominal cavity. It's connected all the way around the inside of the rib cage and costal cartilages. And the roof of the parachute is called the central tendon. On the top side of the roof, the diaphragm connects to the bottom of the pleura and the pericardium. If everything works right, only three large tubes pass through the diaphragm, the aorta, the vena cava, and the esophagus. Nerves, the thoracic duct of the lymphatic system, and smaller blood vessels that wrap around some of these structures also pass through, but the vena cava, aorta and esophagus each have their own special pathway. The esophagus passes through an opening called the esophageal hiatus, which occurs around the level of T10. The word hiatus means gap or opening. When someone goes on hiatus from their job, it means they're taking a break.

0:05:04.7 RW: When we have an anatomical hiatus, it means there's an opening in a structure, usually so that something else can pass through. We do have other hiatuses. Yes, that's the plural, I looked it up. The spot where the aortic and thoracic duct passed through the diaphragm is called the aortic hiatus. There's an adductor hiatus, where the femoral artery and vein pass, and some hiatuses and bones too, especially some of the facial bones. So here we have the esophagus, literally, tube for eating, esophagus, that passes from the throat to the stomach, and along the way it goes through a hole in the central tendon of the diaphragm, the esophageal hiatus. And when things work well, the stomach stays on the inferior side of the diaphragm. And when they work less well, the esophageal hiatus can stretch or widen and pressure from the abdomen can push the stomach upward into the thoracic cavity. Of course, this is not ideal. The stomach is not invited into the thoracic cavity. The structures that live in there, the heart and the lungs, they need all the space they have, so they can do their important work. And when the stomach butts in, they get compressed and can't work as well.

0:06:16.1 RW: Furthermore, the lining of the esophagus is not as protected from corrosive digestive juices as the stomach is, so if there's any backsplash from the stomach, such as might happen when the stomach is pinched in the wrong place, that can lead to trouble too. So at this moment, I wanna take a very short detour into that concept, backsplash of gastric acid from the stomach into the esophagus. You probably know that this is GERD, gastroesophageal reflux disorder. GERD can occur when the lower esophageal valve, that's the door that separates the esophagus from the stomach, is weak. That door can weaken independently as a free-standing disorder, but GERD is also a common complication or symptom of hiatal hernia. Hiatal hernias come in four flavors. Type 1 or sliding type represents more than 95% of hiatal hernias, and this happens when the gastroesophageal junction passes up and down through the hiatus. There's a lovely picture of this from Wikimedia comments that I will include in our show notes.

0:07:24.8 RW: Type 2 is a para-esophageal hiatal hernia, which is what happens when part of the stomach pushes into the thorax alongside the esophagus, but the gastroesophageal junction is still stable on the bottom side below the hiatus. Type 3 is both a para-esophageal hernia and a sliding hernia, where the gastroesophageal junction and a portion of the stomach push upwards into the mediastinum. And Type 4 is when the stomach and other organs like the colon, the small intestine or the spleen may herniate up into the chest. Hiatal hernias, especially the Type 1 version, are incredibly common. They're often sub-clinical, that is, they cause no symptoms and they're only found incidentally when a person is being tested for something else, that's how mine was found, when we were doing some testing to get at the case of my cough. The sliding hernia was not it. According to the Cleveland Clinic, which of course, is linked in your show notes, about 55% to 60% of individuals over age 50 have a hiatal hernia.

0:08:33.3 RW: But only about 9% of them have symptoms. The vast majority of those hernias are Type 1 sliding hiatal hernias. Women are affected more often than men. That could be related to the increased intra-abdominal pressure we experience during pregnancy. What might cause the stomach to protrude up through the esophageal hiatus? Well, age has a lot to do with this. Other predisposing factors include high intra-abdominal pressure, like we see with pregnancy, or obesity, or chronic constipation, and interestingly also, with chronic obstructive pulmonary disease or COPD. And the problems that ensue from hiatal hernia involve indigestion, of course. But there's more. There's just not a lot of spare room in the mediastinum, and if a substantial portion of the stomach protrudes into that neighborhood, lung function is limited and even the heart can be affected. Back in the olden days, the home cure for hiatal hernia was to drink a lot of water, and then to jump up and down. The thought was that this would way down the stomach and pull it out of the hiatus. The problem with this, of course, is that it is a temporary solution to a long-term problem, and it's not gonna work if the stomach is being drastically strangulated at the diaphragm, which is what happened to Nancy Dail.

0:09:56.4 RW: So here's what Nancy told me about her admittedly unusual experience with hiatal hernia. It began with a new onset of pain, not in her gut and not heartburn, but in the right trapezius that went up into her neck. She said it felt like a brick. She tried massage, chiropractic, ultrasound, electro-stim. Nothing would touch it. She learned later that this is the referred pain pattern for stomach pain. A cardiologist ruled out pericarditis, but she had worsening problems with taking a deep breath. Then she had a hard fall and she fractured a couple of vertebrae. And another result of this trauma meant that her hernia enlarged and a portion of her stomach lifted into the mediastinum. Interestingly, she never had difficulty with heartburn, but she attributes that to very careful management of her diet. Nonetheless, she lost 40 pounds because she couldn't eat... She's just felt full all the time. When she finally got to a gastroenterologist to do a barium swallow, she could watch the action of her upper GI tract, and they determined that she has an hour-glass stomach, that means part of the organ is in her chest, and then there's a long, narrow passageway to the lower part of her stomach, below the diaphragm. This is a Type 3 hiatal hernia. The displacement of her lungs means Nancy cannot take a deep breath. When she teaches, she must be seated or she can't get enough air to talk, which means teaching hands-on work is especially challenging.

0:11:34.7 RW: Nancy is now due for a surgical repair, which will be done with robotic assistance, but again, her surgery has been postponed several times because of COVID cases at her local hospital, and she's waiting for the call. There are lots of ways to repair the diaphragmatic hiatus, depending on how severe the situation is, but of course, this is major surgery with substantial risks for complications. Watchful waiting in severe cases is even riskier though, because this can result in serious repercussions, like gastric volvulus, where the stomach twists and material can't pass through, or gastric necrosis, where tissue in the stomach dies. What about massage for someone with this situation? Well, I looked up visceral massage or visceral manipulation for hiatal hernia, and I found several suggestions for body work and Type 1 hernias, the sliders, which are so closely associated with GERD. I'll put a couple of links for this in the show notes but I wanna emphasize that this is advanced work that is, in my opinion at least, not for dabbling. Partly because we and our clients don't have the tools to delineate, whether symptoms are related to a Type 1 or a more severe version of this problem.

0:12:53.2 RW: Also, I didn't pursue these enough to know if the practitioners' claim that visceral massage offers anything like a permanent solution. If someone wants to educate me about that, I am willing to learn. And I would add that if you do this search, you will mostly find people who are advertising their work. That doesn't mean their work isn't useful, but it's not the same as formal research about effectiveness or safety. Nancy receives massage regularly, but she does not receive any abdominal work at this point. She says she's perfectly comfortable lying flat in a prone or supine position, but she cannot be on her right side, so that is a consideration for people with any type of hiatal hernia. And some people may also find that lying flat exacerbates their heartburn, so we may have to think about working in a semi-reclined position. She also adds, it took her many months and a variety of doctors to reach the conclusion that she has a very serious situation going on, and she wants to encourage massage therapists to support clients in their own struggles, to be persistent about getting the healthcare they need.

0:14:03.1 RW: Hey everybody. Thanks for listening to I Have a Client Who... Pathology Conversations with Ruth Werner. Remember, you can send me your "I have a client who" stories to ihaveaclientwho@abmp.com. That's ihaveaclientwho, all one word, all lowercase, at abmp.com. I can't wait to see what you send me, and I'll see you next time.

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