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Sports Hernia- some practical advice

Sports Hernia- some practical advice

Sports hernias have become a bit of an enigma for patients and doctors alike.  Evaluating and treating patients at the Virginia Heartburn and Hernia Institute has given us a unique perspective on what types of injuries will respond to minimally invasive procedures. If you are a frustrated patient or clinician please review this article.

Of all the conditions evaluated in my office the one with the honor of having the most money and time spent on itsports hernia with the least satisfactory results prior to our evaluation are the patients with “sports hernias”. Not everyone is a “professional” or even a serious athlete although those groups do tend to dominate when it comes to spending a lot of their money on MRIs, physical therapy, acupuncture and visits to their favorite Orthopedic surgeon. I see plenty of casual athletes, clumsy gardeners, former active duty military, and yoga moms with the same complaints as famous athletes. The problem is the name. Hernias are supposed to be holes and “sports hernias” don’t have holes.

Orthopedic surgeon’s training focuses on bones, joints, cartilage and the structures that hold these things together- they don’t fix “holes”. General Surgeons are trained to do many complicated things that typically involve the softer part of our anatomy like the skin, breast disease, abdominal organs, etc. We are great at fixing “holes” in things be it in the intestine, a blood vessel or the abdominal wall (hernias). We have national societies in the field of General Surgery that are single-mindedly devoted to just fixing hernias. Some General Surgeons devote their entire career to figuring out how combine anatomy, technology and mesh products to give patients the best and most durable hernia repairs.

When an injured patient has exhausted and frustrated him or herself trying to get their groin pain to go away they may end up in the office of a General Surgeon at some point. If the gold-standard “turn your head and cough” fails to reveal a obvious outward bulge through the muscle (indicating a repairable defect or “hole” in the muscle), the patient is often told that they don’t seem to have a hernia and the cycle starts again with imaging studies, physical therapy and trips to the Orthopedic Surgeon.

So… who is right and who is wrong? Crazy as it seems everyone is right. The patient really has a problem, the Orthopedic Surgeon is correct in finding nothing wrong with the bone or joints and the General Surgeon is correct in stating that you do not have a hernia. What you have typically is a very poorly named constellation of injuries and partial tears in the lower abdominal wall that was created when your torso twisted one way while your leg was going the other. That torque creates tears in the tissues of the abdominal wall muscles and the fibers that anchor it to the pelvic bone. Repetitive activity makes it worse, rest may allow repair to occur in most people but not all. Because the pain often is localized to the inguinal crease or groin the patient may describe a pain pattern that sounds like hernia in the same region. Thus the name “sports hernia” has been inappropriately born and assigned.

It is hard for any applied therapy to have good results in any area of medicine if the physician involved is not really certain what they are treating. This is one of the reasons there is so much disagreement among “experts” and why there are so many variable therapies with variable results. To use a really horrible sports analogy- some times we get lucky and hit the ball even if our eyes are closed. It is not that anyone is intentionally doing the wrong thing it is just hard to get good results when the problem is not well defined or well understood.sports hernia To be blunt most General Surgeons have never been trained how to evaluate a sports hernia and many have never thought about the issue till someone shows up in their office. In that circumstance it makes sense to “do no harm” and send the patient back to the referring doctor save someone from what might be a pointless and potentially chronically painful operation.

Even among those Surgeons who either intentionally or unintentionally become involved in the evaluation of the “sports hernia” there is no universal agreement on what repair to do. Some have devoted their entire practice to the endeavor and most have settles into a routine surgical procedure that makes the most sense to them and gives them functional outcomes that they feel are predictable and reasonable. These procedures are typically done with an open groin incision. They can be fairly complicated and often require a specific post-operative regiment of physical therapy to achieve a maximal benefit. Patient will often travel great distances and spend a lot of time, effort and money seeking out these devoted centers. Some like myself believe that the majority of patients will do quite well with a laparoscopic minimally invasive repair with a rapid recovery and reserve the more intense “open” repairs for specific cases or treatment failures. The laparoscopic repair allows the damaged tissue to be reinforced or “splinted” internally with a lightweight mesh. It probably doesn’t hurt any of my patient’s feelings that their insurance actually covers these repairs and it is rare that any post surgical “rehab” is required.
It is hard to accurately judge the results of interventions when it comes to the “sports hernia” patient. There currently exists no standard of care with respect to evaluation and intervention. How can one really judge the failure of conservative management of these conditions when every patient has different expectations of physical performance? How do we evaluate the quality of the surgery when there are no standards of when to intervene or what to do when we get to the operating room? Fortunately this is a benign condition and for most patients they have the luxury of time to find a treating physician that understands this badly named problem.
G. Kevin Gillian, M.D., F.A.C.S.
Virginia Hernia and Heartburn Institute

Anti-reflux and Heartburn: MEDICARE SPENDS MORE ON NEXIUM THAN ANY OTHER DRUG

 

Anti-reflux and heartburn prescriptions

Medicare spending on anti reflux and heartburn prescriptions is enormous. A recent Wall Street Journal article reported that Nexium was the single most costly drug in terms of overall cost. At first glance the numbers are mindboggling.   There were 8,192,362 prescription claims for Nexium in 2013 for Medicare.Slide30 antacids

GERD and Proton Pump Inhibitors: Are PPI’s Safe?

GERD and Proton Pump Inhibitors

Proton pump inhibitors have become one of the most heavily prescribed types of medications in the United States. The names of these medications have become familiar even to people who don’t have reflux. Protonix, Nexium, Dexilant, Aciphex and others have become almost as familiar to folks as Pepsi and Coke.
The fact that they are so ubiquitous leads many patients and doctors to assume that they are harmless. Research in this area is beginning to lead many patients and physicians to re-think this assumption and the risk/benefit of long-term usage of these medications.

To be fair, these medications provide an enormous benefit to many patients. Their ability to block the production of acid in the stomach allows ulcers to heal and greatly reduces the symptoms of gastro-esophageal reflux or GERD. These medications make people feel better and they do not want to stop taking them because GERD symptoms rapidly return when the medications are stopped in about 80% of patients. Despite the fact that the FDA has advised that no more than three 14-day courses be used on any given patient in a one year period most people take them on a daily basis for years. Subsequently we are seeing unanticipated side effects.

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Although many of the documented side effects are mild many patients are starting to question the wisdom of long-term use. Recent news has begun to highlight some of the more dramatic risk factors, particularly heightened cardiac risks. Some have suggested the increased risk of heart attack among PPI users is up to 21%.

Proton pump inhibitors may increase heart attack risk.
The New York Times (6/11, Bakalar) “Well” blog reports that research published in PLOS One suggests that “proton pump inhibitors…may increase the risk for heart attack.”
The Washington Post (6/11, Bernstein) “To Your Health” blog reports that “after combing through 16 million electronic records of 2.9 million patients in two separate databases,” investigators “found that people who take the medication to suppress the release of stomach acid are 16 percent to 21 percent more likely to” experience a heart attack. Nicholas J. Leeper, an author of the study, “said the Food and Drug Administration ‘should be aware of these findings,’ but agreed that only a large, prospective clinical study…could establish whether the drugs are actually causing more heart attacks.”
On its website, CBS News (6/11, Seidman) reports, however, that “analysis of patients using another type of antacid drugs called H2 blockers…did not show this increased risk.”

This is a tremendously important issue as PPI’s account for BILLIONS of health care dollars being spent every year just in the USA. They are often being taken in a manner that is contrary to FDA recommendations and they may be putting many patients at risk for problems they may not be aware of. I personally see patients every month who are seeking surgical control of their reflux so that they can avoid the possible consequences of long term PPI use.

GERD

Gastroesophageal reflux disease, or GERD, is a digestive disorder that affects the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach.

Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach’s contents back up into the esophagus.

In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach’s contents to flow up into the esophagus.

Is GERD Causing Your Cough?

GERD, heartburn, hernia

 

Is GERD causing your cough?

There are many reasons one may have a cough and GERD could be one of them. “Coughing is a protective mechanism your body uses to clear the airway,” explains Dr. Kevin Gillian, MD at The Virginia Heartburn and Hernia Institute in Lorton, VA. But what causes a cough? It turns out that it could be a multitude of things ranging from allergies to acid reflux to GERD. It’s impossible to always pinpoint the cause of a cough by how it sounds and for a persistent cough; you should always visit your physician. However, there are some key differences in coughs that may give you clues as to what’s going on.

Postnasal drip

This can be either a wet or a dry cough. Mucus dripping down your throat (due to either allergies or a cold) tickles your nerve endings and triggers coughing.

Other symptoms of a cough caused by postnasal drip may include; increased coughing at night and a tickly feeling at the back of your throat. If postnasal drip is caused by allergies, itchy eyes and sneezing may accompany the coughing.

If you suspect your cough is being caused by allergies, an over-the-counter antihistamine may help. If your coughing is caused by a residual cold, natural remedies like saline washes and steam could help relieve congestion, If your symptoms do not improve in 7 -10 days, see your doctor to rule out a sinus infection, which might require antibiotics.

Asthma

A dry cough that ends with a rattle or wheeze may be caused by asthma. Asthma is a condition that is marked by airway restriction. This can cause difficulty breathing as well as wheezing and coughing.

Other symptoms of a cough caused by asthma may include increased coughing at night and while exercising.

If you think you may have asthma, you will need to see your doctor for diagnosis and treatment of this potentially dangerous condition. If your doctor suspects that you have asthma, he will most likely order a spirometry, a lung function test. . There are two types of medications to treat asthma; quick-relief drugs (bronchodilators, which make it easier to breathe) and drugs you take daily to keep asthma under control.

COPD

A chronic, hacking cough that produces a lot of mucus, particularly in the morning may be indicative of COPD (chronic obstructive pulmonary disease). COPD includes chronic bronchitis and emphysema. The main cause of COPD is smoking.,

Other symptoms of COPD may include decreased coughing as the day progresses; shortness of breath, especially with physical activity; wheezing, fatigue, and chest tightness.

If your doctor suspects COPD, he will usually recommend lung function tests such as spirometry and a chest x-ray. The disease is treated with meds like bronchodilators and inhaled steroids. If diagnosed with COPD, it is imperative to stop smoking. In extreme cases, you may need oxygen therapy

Medication-related cough

A group of drugs known as ACE inhibitors are commonly prescribed to treat high blood pressure. In about 20% of patients, they can cause a dry cough. A medication related cough usually begins a few weeks after starting these medication..

If your ACE inhibitor is causing your cough, talk to your doctor. If your cough is mild, your doctor may switch you to a different ACE inhibitor. If the cough is severe, your doctor may want to switch you to another type of blood pressure medication entirely, such as an angiotensin receptor blocker or ARB.

GERD

GERD (gastroesophageal reflux disease) causes a dry, spasmodic cough. GERD characterized by acid from your stomach backing up into your esophagus. GERD is the second most common cause of chronic cough, causing about 40% of cases, according to a 2006 review published in Nature.

Symptoms of a cough caused by GERD include increased coughing when you’re lying down or eating. Approximately 75% of GERD patients that have a chronic cough caused by GERD have no other symptoms. However, if there are other symptoms present they usually include heartburn, hoarseness and globus ( lump in the throat sensation).. Normally heartburn is an innocuous condition. However, “if chronic heartburn is left untreated, it can lead to Barrett’s esophagus, which is a precursor to gastroesophageal cancer” says Dr. Gillian.

To determine if your cough is caused by GERD, your doctor may order an x-ray of the upper GI tract and/or an endoscopy. Coughing caused by GERD is often not fully controlled by medications and lifestyle adjustments. Minimally invasive laparoscopic operations ike the Nissen Fundoplicaion and LINX procedure control reflux and thus can stop the cough or significantly improve it.

The evaluation of chronic cough from GERD and the surgery to correct it is available at the Virginia Hernia and Heartburn Institute

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