July 7, 2005

Q Please help. Last year the doctor told me I had acid reflux disease. From X-rays he learned that part of my stomach has gone into a hernia. Now my breathing is affected. What will eventually happen to me? I am scared.

A Some anatomy might take the scariness away. The oesophagus is the swallowing tube through which food passes from the mouth to the stomach. At the very bottom of the chest, it passes through a hole in the diaphragm muscle, a horizontal, muscular sheet that separates abdomen from chest.

If the stomach bulges upward into the chest through the hole in the diaphragm, that is a hiatal hernia. Some who have a hiatal hernia, but not all, also have GERD — gastroesophageal reflux disease, aka heartburn. “Reflux” means that stomach acid and digestive enzymes spurt upward into the esophagus, which cannot cope with those corrosive juices like the stomach can. The result is heartburn. People without a hiatal hernia can have GERD, and people with a hiatal hernia do not have to have it. The two are distinct problems.

Antacids can take care of mild and infrequent GERD. For more frequent and more severe GERD, medicines that reduce acid production work — Tagamet, Zantac, Pepcid and Axid. Some can be obtained without a prescription. For even more severe GERD, medicines that turn off acid production are used. Prilosec is an example, and it too is on drugstore shelves.

For the hernia problem, another approach might have to be taken. If the hernia is so large that the entire stomach has entered the chest cavity and is compressing a lung (a most unusual happening), then the answer is surgery. That is not as daunting a prospect as it might sound. Your doctor is not going to let matters progress to the point where your health is threatened.

Q Please give me your take on bariatric surgery.

A Bariatric surgery — weight-loss surgery — has a place in the treatment of people whose weight constitutes a health hazard and for whom all else has failed in an attempt to lose it.

Health-threatening obesity is body weight that puts the body mass index — BMI — at 40 or above. The BMI is obtained by dividing weight in kilograms by height in metres squared. To calculate it using pounds and inches, multiply weight by 704, divide that number by height in inches and then divide that result once more by height in inches. A normal BMI is 18.5 to 24.9.

A pound estimate of dangerous weight is 100 pounds greater than the ideal body weight for a man and 80 for a woman.

Morbid obesity, as those weights are called, leads to heart problems, high blood pressure, osteoarthritis, diabetes, sleep apnea and many other health-threatening conditions.

Bariatric surgery does one of the following: creates a smaller stomach that holds less food; rearranges the connection of stomach and small intestine so that less food is absorbed; or employs a combination of both techniques.

Surgery is not to be taken lightly. Serious complications can arise, including death. However, the fact that there are estimated to be 300,000 annual obesity-related deaths in the United States alone gives this-surgery a legitimate role in the treatment of this prevalent illness.

Q You mentioned a new medicine about to come on the market that is as effective as Coumadin in thinning blood without all the fuss entailed in using it. Will you supply the name? I would like to investigate it.

A The generic name is ximelagatran, and the brand name is Exanta. It might be on the market by the time this is printed, or it might take months or years to make it to the public.



Dr Donohue regrets that he is unable to answer individual letters, but he will incorporate them in his column whenever possible. Readers may write to him or request an order form of available health newsletters at PO Box 536475, Orlando, FL 32853-64750

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