Apple Surgical Clinic

Acid reflux, or gastro-oesophageal reflux disease is a very common condition. It occurs when the stomach contents back up into the oesophagus or gullet.

What are the symptoms of gastro-oesophageal reflux disease?
The most common symptom of acid reflux is heartburn – a burning pain behind the breastbone. It is also sometimes referred to as indigestion, usually after a meal. Other symptoms include:

• Regurgitation of acidic tasting fluid into the mouth (“waterbrash”), especially on bending or lying down
• Hoarseness or persistent voice changes and cough
• Feeling of a lump in the throat
• Difficulty with swallowing – seek urgent medical attention if this is a new symptom.

What causes gastro-oesophageal reflux disease?
There is a valve at the lower end of the gullet (lower oesophageal sphincter) which relaxes when we swallow to allow food and drink to enter into the stomach. The same valve also closes when the pressure inside the stomach increases, to prevent the backing up of stomach contents into the gullet. Acid reflux occurs when this valve malfunctions, or is weak, allowing stomach contents to back up into the oesophagus and cause irritation.

A hiatus hernia occurs when part of the stomach is pushed up into the chest cavity through the diaphragm. While acid reflux is not directly caused by this, the presence of a hiatus hernia does predispose an individual to gastro-oesophageal reflux.

How is gastro-oesophageal reflux managed?
A combination of lifestyle changes and over the counter antacid medications can help manage acid reflux as a first step

Lifestyle tips to help control acid reflux:

• Avoid smoking – smoking relaxes the lower oesophageal valve or sphincter
• Lose excess weight – being overweight increases the pressure on the stomach
• Keep meal portion sizes small – large meal portions increase the pressure on the stomach
• Avoid eating meals for 2-3 hours before bedtime
• Avoid alcohol – alcohol weakens the lower oesophageal sphincter
• Avoid fried and fatty food
• Avoid coffee
• Elevate the head of the bed by about 6 inches to minimise acid reflux when lying down
• Take over the counter antacid medication as directed.

If symptoms persist, despite the above measures, you should seek medical advice.

How is gastro-oesophageal reflux disease diagnosed?
Many people will experience occasional heartburn, especially after meals. However, if heartburn occurs more than three times a week, it will be regarded as chronic acid reflux and will need further investigation:

• Gastroscopy or Upper GI endoscopy – This involves passing a thin, flexible tube, with a camera and light source on the end, through the mouth into the oesophagus and stomach. It is then possible to examine these areas for signs of chronic acid reflux, such as inflammation and ulcers from acid burns, as well as complications associated with the condition, such as Barrett’s oesophagus and strictures. Sometimes a tissue sample (or biopsy) may be taken for analysis, or a treatment such as oesophageal dilatation may be carried out at the same time.
• Barium swallow and meal – Very occasionally this X-ray investigation may be required to assess a stricture (narrowing) of the oesophagus. Its role is to provide a road map before embarking on gastroscopy and oesophageal dilatation.
• Oesophageal manometry – This test is used to assess the pressure measurements of the oesophagus and help identify critically low sphincter pressure. It also helps to identify other functional disorders affecting the oesophageal muscle.
• 24 hour pH study – This measures reflux of stomach acid during normal everyday activities, such as eating and lying down, in order to objectively assess the degree of acid reflux. A fine tube, connected to a recording device, is passed through the nose into the oesophagus and left for 24 hours to record the degree of acid reflux.
• Oesophageal impedance studies – This measures the rate of fluid movements at various points along the oesophagus to assess the degree of acid and non-acid reflux. It is often combined with pH monitoring (see above). You will be supplied with a data collection device to record symptomatic reflux episodes throughout the test period. These symptoms are then correlated with the results of the study.

Surgery for Gastro-Oesophageal Reflux Disease (GORD)
Most patients suffering from chronic acid reflux can manage their symptoms well by adjusting their lifestyles and taking acid-suppressing medications. However, some may be candidates for anti-reflux surgery, including those who:

• Constantly regurgitate stomach contents into the back of the throat and mouth, especially on bending and after a meal (volume refluxers)
• Cannot tolerate acid suppressing medications, or do not wish to take these medications long term
• Some patients with chest and airway complications of acid reflux – e.g. voice changes (after excluding other possible causes), worsening of asthma
• When medications fail to adequately control symptoms

What does anti-reflux surgery involve?
The surgery involves wrapping the upper part of the stomach (fundus) around the lower oesophagus to strengthen the lower oesophageal valve. This stops stomach contents and acid backing up into the oesophagus. Any hiatus hernias present are reduced and the hiatus hernia defect closed to ensure there is no recurrence.

The most common operation performed to control chronic acid reflux is called Nissen fundoplication. This is now performed via keyhole surgery which means smaller incisions, less pain, a reduced risk of complications and a quicker resumption of normal activities.

In the majority of patients the surgery is performed under general anaesthesia, as a day case. However, it may be necessary for some patients to stay in hospital overnight for further monitoring.

The operation takes approximately 45 -60 minutes. After the surgery you will be taken to the recovery room for close monitoring until most of the anaesthetic drugs have worn off and then returned to your room.

How effective is anti-reflux surgery?
Laparoscopic anti-reflux surgery (Nissen fundoplication) is effective in controlling chronic acid reflux in over 90% of patients. However, there is a chance that some patients may need antacids further down the line because of a recurrence of their symptoms.

Will I see my surgeon after my operation?
Mr Agwunobi and his team will visit you on the ward before you are discharged from the hospital. You will be given pain killers to take home and details of necessary dietary adjustments during your recovery period.

A follow-up appointment will be arranged for you to see Mr Agwunobi in 4 – 6 weeks’ time to check on your recovery. You will also be given a contact number to call should you have any concerns following your surgery.

What are the potential risks of the operation?
Surgical complications during this operation are very rare, but include general risks of bleeding, wound infection, blood clots and damage to other organs. Mr Agwunobi will discuss these further with you during your consultation.

What are the side-effects of anti-reflux surgery?
Early during the recovery period, you may notice the following:

• Bloating, due to gas or eating too much too quickly– try to eat small but frequent meals, avoid fizzy drinks and eat slowly
• Mild difficulty with swallowing – this is due to swelling caused by the operation and the creation of the new valve. This sensation is usually short lived and settles within 3 months. Try to stick to a soft diet and avoid dry food substances (see dietary advice).
• Excessive flatulence – but again this improves with time.

How long does it take to recover from anti-reflux surgery?
Your physical recovery should take around 7-10 days. We advise a similar timescale before you start driving again, but please check with your insurance company.

Dietary adjustments will need to be made for about 4-5 weeks before you can resume a regular diet.

Do I need to go on special diet after the operation?
You should make dietary adjustments during the first 4-6weeks following anti-reflux surgery. You will be seen by one of our Specialist Dieticians to discuss this.

Please see our dietary advice for more details.

Please ensure you consult a healthcare professional before making decisions about your health.

What is abdominal pain?

Abdominal pain, or stomach ache, is a term often used to refer to cramps or a dull ache in the tummy (abdomen). It's usually short-lived and is often not serious.

Severe abdominal pain is a greater cause for concern. If it starts suddenly and unexpectedly, it should be regarded as a medical emergency, especially if the pain is concentrated in a particular area.

If this is the case phone your GP as soon as possible, or the NHS 111 service if your GP is closed.

If you feel pain in the area around your ribs, read about chest pain for information and advice.

Stomach cramps with bloating
Stomach cramps with bloating are often caused by trapped wind. This is a very common problem that can be embarrassing but is easily dealt with.

A pharmacist will be able to recommend a product such as buscopan or mebeverine, which can be bought over the counter to treat the problem.

Sudden stomach cramps with diarrhoea
If your stomach cramps have started recently and you also have diarrhoea, the cause may be a tummy bug (gastroenteritis). This means you have a viral or bacterial infection of the stomach and bowel, which should get better without treatment after a few days.

Gastroenteritis may be caused by coming into close contact with someone who's infected, or by eating contaminated food (food poisoning).

If you have repeated bouts of stomach cramps and diarrhoea, you may have a long-term condition, such as irritable bowel syndrome (IBS).

Sudden severe abdominal pain
If you have sudden agonising pain in a particular area of your abdomen, phone your GP immediately or the 111 service if your GP is closed. It may be a sign of a serious problem that could rapidly get worse without treatment.

Serious causes of sudden severe abdominal pain include:

• appendicitis – the swelling of the appendix (a finger-like pouch connected to the large intestine), which causes agonising pain in the lower right-hand side of your abdomen, and means your appendix will need to be removed
• a bleeding or perforated stomach ulcer – a bleeding, open sore in the lining of your stomach or duodenum (the first part of the small intestine)
• acute cholecystitis – inflammation of the gallbladder, which is often caused by gallstones, in many cases, your gallbladder will need to be removed
• kidney stones – small stones may be passed out in your urine, but larger stones may block the kidney tubes, and you'll need to go to hospital to have them broken up
• diverticulitis – inflammation of the small pouches in the bowel that sometimes requires treatment with antibiotics in hospital

If your GP suspects you have one of these conditions, they may refer you to hospital immediately.

Sudden and severe pain in your abdomen can also sometimes be caused by an infection of the stomach and bowel (gastroenteritis). It may also be caused by a pulled muscle in your abdomen or by an injury.

Long-term or recurring abdominal pain
See your GP if you or your child have persistent or repeated abdominal pain. The cause is often not serious and can be managed.

Possible causes in adults include:

• IBS – a common condition that causes bouts of stomach cramps, bloating, diarrhoea or constipation, the pain is often relieved when you go to the toilet
• inflammatory bowel disease (IBD) – long-term conditions that involve inflammation of the gut, including Crohn's disease, ulcerative colitis and endometriosis
• a urinary tract infection (UTI) that keeps returning – in these cases, you'll usually also experience a burning sensation when you urinate
• constipation
• period pain – painful muscle cramps in women that are linked to the menstrual cycle
• other stomach-related problems – such as a stomach ulcer, heartburn and acid reflux or gastritis (inflammation of the stomach lining)

Possible causes in children include:

• constipation
• a UTI that keeps returning
• heartburn and acid reflux
• abdominal migraines – recurrent episodes of abdominal pain with no identifiable cause

What is anal pruritus (anal itching)?
Anal pruritus is itching of the anus or the skin around it. The anus or the back passage is the last part of the digestive system. It is where bowel movements leave the body.

Anal itching can cause discomfort and embarrassment. Some people think it means they have colon cancer. But anal itching is usually caused by something else.

What causes anal itching?
There are many possible causes of anal itching, including:

• Part of a bowel movement that gets stuck to the skin around the anus – This is more likely to happen if you have diarrhoea or soft bowel movements.
• Haemorrhoids – These are swollen veins in the rectum. They can also cause pain.
• Certain foods or drinks, which can irritate the anus, such as:
• Coffee, tea, beer, and cola
• Chocolate
• Tomatoes
• Citrus fruits, such as oranges or grapefruit

Diseases that affect the anus, such as:

• Infection or anal abscess – This is a lump that happens when a gland inside the anus gets infected.
• An anal fistula – This is a tunnel that forms between the anal gland and the place where the abscess is on the skin.
• Cancer – Some people who get anal, rectal, or colon cancer have anal itching.

Skin diseases, such as:

• Psoriasis – A skin condition that can cause a rash and itching.
• Allergic reaction (dermatitis) – A skin rash that can happen after your skin touches something that irritates it or something you are allergic to. This could be a skin cream, laundry detergent, or something else that touches the area around your anus.
• Diseases caused by infection with a bacteria or fungus.

Is there anything I can do on my own to get rid of anal itching?

There are some things you can try. These include:

• Keeping the anus and skin around it clean and dry – You can:
• Wipe gently after a bowel movement, using a moist pad or tissue (baby wipes are very useful)
• NOT use a cleaning lotion, or detergents – This can make symptoms worse.
• Take a bath after you have a bowel movement whenever practical – Use mild, unscented soap. Pat the area dry with a soft towel or use a hair dryer on the cool setting.
• Put some unscented talcum powder on the skin around the anus – This can help keep the area dry.
• Putting an anti-itch ointment on the area – You can use an over-the-counter steroid cream. But do not use anti-itch cream for more than 2 weeks.
• Putting a zinc oxide skin ointment or paste on the area.

You can also try NOT eating or drinking things that can cause anal itching or diarrhoea. For example, some people get diarrhoea when they drink milk or eat foods made with milk.

Will I need tests?
In some cases you may require tests. Your doctor or nurse will do an examination and learn about your symptoms.

You might also have the following tests:

• Biopsy – If the doctor or nurse finds a growth, he or she will take a small sample of tissue from the area. Another doctor looks at the sample under a microscope to check for cancer.
• Colonoscopy – This test looks at the inside lining of a person’s large intestine, called the “colon.” During a colonoscopy, the doctor puts a tube with a tiny camera into your anus and up to your colon. This lets the doctor look for cancer or other problems. Before a colonoscopy, you get medicine to make you relax.

How is anal itching treated?
If a medical condition is causing the anal itching, doctors can treat that condition. This usually gets rid of the itching.

A few people have anal itching even after trying different things to stop it. If this happens, doctors can give other ointments that can stop the itching.

Can anal itching be prevented?
You can reduce your chances of getting anal itching by:

• Keeping the area around the anus clean and dry
• NOT eating foods that can cause anal itching or diarrhoea.

What is Barrett’s oesophagus?
Barrett’s oesophagus is a complication of acid reflux whereby the lining of the oesophagus changes from the normal pinkish-white, flat (squamous) cells to the bright salmon/red coloured rectangular (columnar) cells found further down the gastrointestinal tract.

It is caused by the stomach contents and acid repeatedly leaking (refluxing) back up the lower oesophagus, causing inflammation and abnormal cell formation. This can vary from mild (low grade dysplasia) to severe (high grade dysplasia) and if left untreated can, in rare cases, increase the risk of cells turning cancerous.

What are the risks of Barrett’s oesophagus?
Although Barrett’s oesophagus can progress to cancer, this risk is very small and only occurs in around 1 in 200 (0.5%) patients with Barrett’s oesophagus per year.

What are the symptoms of Barrett’s oesophagus?
There are no specific symptoms of Barrett’s oesophagus but it is more likely if you have had symptoms of acid reflux, or heartburn, for ten years or more.
Barrett’s oesophagus is sometimes detected when an upper GI endoscopy is performed for another unrelated condition.

Factors that predispose people to developing Barrett’s oesophagus include:

• Male
• Aged over 50 years
• Obesity
• Smoking
• Chronic acid reflux for over 10 years, or symptoms of acid reflux more than 3 times a week.

How is Barrett’s oesophagus diagnosed?
Two criteria have to be fulfilled to diagnose Barrett’s oesophagus:

• ndoscopic confirmation of abnormal, salmon pink lining in the lower oesophagus, near to the oesophago-gastric junction.
• Pathologic identification of cells with the specialised intestinal metaplasia characteristic. A specialist gastroenterology pathologist is required for accurate interpretation of the findings.

How is Barrett’s oesophagus managed?
How the condition is managed depends on whether there is any dysplasia or not.

With only mild, or no dysplasia, management will include:

• ifestyle changes, as for chronic acid reflux
• Symptom control with antacid medications
• Anti-reflux surgery may be preferred by some patients for symptom control
• Regular monitoring with endoscopy, to look out for worsening of cell changes.

High grade dysplasia is managed more intensively because of the greater risk of progression to oesophageal cancer. It may include some, or all, of the following:

• ntensive endoscopic monitoring every 6 months, with multiple tissue sampling at 1cm intervals
• Endoscopic mucosal resection – removing the affected oesophageal lining through the endoscopy
• Photodynamic therapy (PDT) – to kill the irregular oesophageal cells
• Oesophageal resection in suitable candidates

There are other treatment options currently undergoing clinical trials. You will be advised of the most suitable option(s) for you.

Please ensure you consult a healthcare professional before making decisions about your health.

Gallstones and Gallbladder Removal

How are Gallstones formed?
Gallstones are solid materials, made up of crystallised cholesterol and bile salts. Gallstones can range from the size of a grain of sand to the size of a golf ball.

It is not clear why some people get gallstones, but there are factors that increase your risk, including:

• Being female
• Aged over 40
• Obesity
• Rapid weight loss – e.g. after weight loss surgery or a crash diet
• Oestrogen, as found in HRT and birth control pills
• Diabetes
• Cholesterol lowering drugs

The Gallbladder
The gallbladder is a small sac, about the size and shape of a pear, which lies under the liver on the right side of the upper abdomen. It is connected to the liver and the bowel through tubes known as the cystic and the common bile ducts. The role of the gallbladder is to store and concentrate bile produced by the liver and release it to aid food digestion.

What are the symptoms of gallstones?
The most common symptom of gallstones is pain, usually in the right upper abdomen. However, it can sometimes feel like a tight band running across the whole area and the pain may also radiate to the back, between the shoulder blades. This is sometimes referred to as “biliary colic” and may be associated with nausea and vomiting. The pain can last from 15 minutes to several hours and attacks of pain may be separated by weeks, months, or even years, with no defined pattern.

Some patients with gallstones experience no symptoms and the stones are only discovered by chance. No treatment is required for silent (asymptomatic) gallstones.

Complications of Gallstones
Gallstone pain occurs when a stone blocks the cystic duct. If this is prolonged then it may cause inflammation and infection of the gallbladder – a condition known as acute cholecystitis. This is usually an emergency and requires hospital admission for pain control and antibiotics, as well as urgent surgery to remove the gallbladder.

Gallstones can also move and lodge in the main bile duct causing an obstruction. This will lead to jaundice, dark urine and skin itching. Some people will also develop a fever and shaking which requires urgent medical attention.

Inflammation of the pancreas (acute pancreatitis) is a potentially life-threatening complication of gallstones. This can occur when a gallstone blocks the common channel of the main bile duct and the pancreatic duct, where they both drain into the bowel (duodenum). This requires urgent hospital admission and management.

How are gallstones diagnosed?
Gallstones are diagnosed by:

• n assessment of a patient’s clinical history and symptoms
• An ultrasound scan of the abdomen (most common)
• A CT scan may also be used, but this is less accurate than ultrasound in diagnosing gallstones
• MRCP, or Magnetic resonance cholangiopancreatography (MR Scan), which uses a large magnet and radio waves to give clear images of the bile ducts, gallbladder, and pancreas. It can diagnose stones in the gallbladder, as well as those that may have moved into the bile ducts
• Endoscopic ultrasound, which is a highly specialised test combining endoscope and ultrasound techniques. This can get very close to the gallbladder and bile ducts to produce more accurate results than traditional ultrasound.

How are gallstones treated?
There is generally no need to treat gallstones that are not causing any symptoms. However, patients experiencing pain will probably see their symptoms recur at some point in the future which, in a small minority of cases, can lead to life-threatening complications. Under these circumstances, it is advisable to consider treatment.

The best option is to remove the gallbladder with the stones. This is known as a cholecystectomy and is routinely performed using laparoscopic or keyhole surgery. The operation is performed under general anaesthetic (asleep) and takes about half an hour to complete.

Preparing for a gallbladder operation
Once you have decided to have your gallbladder removed, we may recommend blood tests to check your liver and kidney function, a blood clotting test and possibly an ECG to check your heart trace (dependent on your age and medical history). You may also need to temporarily stop taking some medications, such as blood thinning drugs. However Mr Anselm Agwunobi will be able to advise you.

After discussing the pros and cons of your operation we will need you to sign a written consent form to confirm that you are happy to go ahead with the procedure.

You will also receive instructions about reporting to the hospital on the day of your operation and when to stop eating and drinking in preparation for your surgery.

Once at the hospital, you will be taken to your room with its own en-suite facilities. The Apple Surgical Clinic team will admit you and check that everything is in order to proceed with the operation.

What happens during a gallbladder removal operation?
Mr Agwunobi will remove your gallbladder in a procedure known as a laparoscopic cholecystectomy. This will involve making small incisions in your abdomen and inserting a laparoscope, connected to a special camera, giving magnified views of the internal organs.

Tiny, long instruments are used to reach the gallbladder which is then removed from its liver bed. The small skin incisions will be closed with dissolving sutures (stitches), so there is no need for future removal.

You will be asleep throughout the whole procedure (under general anaesthesia) and you won’t feel anything.

Very occasionally it may not be possible to complete the procedure using the keyhole technique and an open cut has to be made to remove the gallbladder. In our practice, this is very rare and over 99% of operations are completed laparoscopically, even in patients who have had previous open abdominal operations.

What to expect after a gallbladder operation:

• You will return to the recovery room for close monitoring before being discharged back to your own room. The ward nurses will continue to monitor and support you on the ward to aid your recovery.
• You may experience some shoulder tip pain, which can be due to the carbon dioxide gas used during the operation to distend the abdomen. This can irritate the diaphragm, which has the same nerve supply as the shoulders, but it should pass off very quickly.
• Adequate pain control will be provided, as well as anti-sickness medications if you feel nauseous.
• You may eat and drink a few hours after surgery, starting with small portions.
• Most patients are able to go home the same day, although a minority may need to stay in overnight for further monitoring.
• You will be discharged home with painkillers to take for 4 – 5 days.
• A follow-up appointment will be arranged for you to see Mr Agwubi again in 4 – 6 weeks’ time.
• Your skin wounds will be dressed with waterproof dressings so that you can have showers at home. These may be removed after 5 days and the stitches will dissolve themselves.
• Full recovery and return to work should take around 7 – 14 days, depending on the type of job you do.
• You may be able to drive 7 days after your surgery, or when you feel able to do an emergency stop, but please check with your insurer.

What are potential complications of a gallbladder operation?
Complications are rare and over of 99% of patients have a smooth recovery and see their symptoms resolved.

Very occasionally patients may experience excessive bleeding, infection, injury to the bile duct, or retained stones. These small risks will be discussed with you at your consultation.

Please contact us immediately if you experience any of the following problems during your recovery:

• Fever
• Yellow skin or eyes (jaundice)
• Bleeding
• Worsening abdominal pain and distension
• Persistent nausea and vomiting
• Redness and discharge from one of your wounds.

Are there any long-term consequences of not having my gallbladder?
You can live perfectly fine without your gallbladder. Your body will adjust.

In a small minority of patients, there may be an increase in bowel frequency, but this is usually temporary and rarely requires any form of treatment.

Do I need to follow a special diet after my gallbladder operation?
You do not need to follow any special diet after your gallbladder operation. Stick to a healthy, balanced diet as usual, but it may be better to eat smaller portions initially until you are able to manage larger meals.

What are haemorrhoids?
Haemorrhoids (also known as “piles”) are swollen blood vessels (veins) near the back passage.

What are the symptoms of haemorrhoids?
Haemorrhoids can cause itching and pain around the back passage. Sometimes they bleed during a bowel movement typically with bright red blood on toilet paper on wiping or splashed on the pan.

In some cases, you can see or feel haemorrhoids around the outside of the back passage. In other cases, you cannot see them because they are hidden inside the back passage.

Other symptoms of haemorrhoids include wetness around the back passage, minor leakage of faeces, mucus discharge and a sense of fullness around the back passage. Occasionally they can become acutely painful and swollen if they contain blood clot (thrombosed).

Should I see a doctor?
You should see a doctor or other healthcare professional if you have any bleeding from the back passage or if your bowel movements look like tar. Bleeding from the back passage could be caused by something other than haemorrhoids, so you should have it checked out.

If you do have haemorrhoids, your doctor can then suggest appropriate treatments. But there some steps you can try on you your own first.

What can I do to avoid getting haemorrhoids?
The most important thing you can do to avoid getting haemorrhoids is to avoid getting constipated. You should have a bowel movement at least a few times a week. Avoid straining when you have a bowel movement.
Being constipated and having hard stools can make haemorrhoids worse. Here are some steps you can take to avoid getting constipated or having hard stools:

• Eat lots of fruits and vegetables. They have fibre, which helps to increase bowel movements.
• If necessary supplement your fibre intake with fibre powders. You should aim to consume 20 to 35 grams of fibre a day.
• Take medicines called stool softeners such as docusate sodium (Dulcolax) or bulk forming laxatives. Bulk forming laxatives such as ispaghula (fybogel) may be taken one sachet a day. These medicines increase the number of bowel movements you have. They are safe to take and they can prevent problems later.

What can I do to reduce my haemorrhoid symptoms?
Sitz bath – some people feel better if they soak their buttocks in 2 or 3 inches of warm water. You can do this up to 2 to 3 times a day for 10 to 15 minutes. Do not add soap, bubble bath, or anything to the water as they act as irritants and may make matters worse.

There are also remedies or medicines that you can get without a prescription. They are usually creams or ointments that you rub on your anus to relieve pain, itching, and swelling. Some hemorrhoid medicines come in a capsule (called a suppository) that you put inside your back passage. Others come in a cream that comes in a bottle with a nozzle that you can insert inside your back passage. It is fine to use these medicines as long as you need them, however, avoid using medicines that contain hydrocortisone (a steroid medicine) for more than a week, unless your healthcare provider approves.

What if the above self-care methods do not work?
If you still have haemorrhoid symptoms after trying the steps listed above, you might need treatments to destroy or remove the hemorrhoids.

One popular treatment is called “rubber band ligation.” For this treatment, the doctor ties tiny rubber bands around the haemorrhoids. A few days later the haemorrhoids shrink and fall off. The doctor can also inject chemicals to destroy haemorrhoids. But if none of these options works, there is always surgery to remove the haemorrhoids.

Please ensure you consult a healthcare professional before making decisions about your health.

A hiatus hernia occurs when part of the stomach pushes up into the chest through the diaphragm.
The diaphragm is a muscle that separates the chest cavity from the abdominal cavity. The gullet goes down the chest cavity through a gap (hiatus) in the diaphragm before joining the stomach. When part of the stomach goes through the hiatus into the chest, a hiatus hernia is formed.

What causes a hiatus hernia?
A hiatus hernia occurs when the diaphragmatic muscle becomes weak, stretching the hiatus and allowing the top part of the stomach to bulge through into the chest cavity.

It is not always clear why a hiatus hernia has occurred, but there are a number of factors that increase your risk, including:

• Aged 50+
• Female
• Obesity
• Pregnancy

Types of hiatus hernia:

There are two main types of hiatus hernia:

• Sliding hiatus hernia, or type 1 hiatus hernia – This is by far the most common type (80%). The top of the stomach pushes up into the chest at the junction of the gullet and the stomach.
• Para-oesophageal hernia, rolling hiatus hernia, or type 2 hiatus hernia – These make up about 15% of all hiatus hernias. In such cases the stomach goes up into the chest alongside the gullet, with the junction between the gullet and the stomach often remaining inside the abdomen.

What are the symptoms of a hiatus hernia?
Small hiatus hernias don’t usually cause any symptoms and are often discovered incidentally while carrying out other investigations.

However, hiatus hernias can cause symptoms such as:

• Chronic heartburn or gastro-oesophageal reflux disease
• Regurgitation and vomiting
• Choking sensations
• Difficulty swallowing
• Excessive belching
• Upper abdominal pain

How is a hiatus hernia diagnosed?
A hiatus hernia may be discovered while investigating causes of upper abdominal pain.

If suspected, the following tests will help confirm the diagnosis:

• Upper GI endoscopy or gastroscopy
• X-ray of the chest and upper abdomen, or barium swallow/meal
• CT scan (especially in complex para-oesophageal hiatus hernias)

How is a hiatus hernia managed?
Sliding hiatus hernias do not necessarily cause symptoms and treatment may focus on managing the associated chronic acid reflux including: lifestyle changes, antacid medications and in a small group of patients, anti-reflux surgery.

Para-oesophageal hiatus hernias may cause difficulty with swallowing and abdominal pain, especially after eating. Sometimes the pain is relieved by vomiting, suggesting intermittent stomach obstructions.

Surgical repair is usually necessary to alleviate these symptoms and prevent the risk of stomach twisting (volvulus), which can lead to strangulation/perforation of the stomach in a minority of patients.

Please ensure you consult a healthcare professional before making decisions about your health.