The physiology of a Hiatal Hernia When Diving?

[Canyondreamer]

I am a physician AND an avid (new) SCUBA Diver - got certified in July 2011, certified Master Diver (SSI) and have just completed my 80'th dive. I dive all year, local reservoirs and lakes as well as Hawaii, Australia, New Caledonia, Vanuate, Fiji, Mideterranian, Bahama etc. Have my own equipment and then some, including dry-suit - so all-in-all trying to really be serious about catching up with my learning about my late-in-life newfound passion!!

I am super healthy and a vigorous work-out buff, doing 60-90 min cardio on average 5 times/week.

Over the last 3 months my exercise endurance steadily decreased and over the last month I got dizzy when I stood up from sitting, thinking I was just getting old (I am 61) and being a physician, I of course did not do what I tell everyone else to do for much too long, which is to have such symptoms checked out!. Eventually I got some blood work that showed I was profoundly Anemic (hematocrit of 20% compared to my usual 55%), and was acutely admitted and underwent a million dollar work-up that showed no other abnormalities other than a pretty good sized hiatal hernia (which I had known for years I had, but which should cause no trouble), but with no evidence of bleeding from it. I got tranfused and given iron and my hematocrit went up to 33% prior to a 2 day diving trip to the Bahamas this last weekend. Did 7 good (wreck) dives in the 50-80 foot range and had no symptoms. But lo-and-behold, when I came back, my hematocrit had dropped down to 25% in the 4 days since I had the 33%. This clearly suggested that diving had/has something to do with my blood loss.

When I h ad my millionp-dollar work-up, I had not been diving in the 3 weeks prior (though usually dive every other week).

So since the only major change in my lifestyle over the past 12 months is my 80 dives since my certification in July 2011 (which some, i.e. my wife, consider insane!), I am now wondering whether the pressure differences between the chest and abdomen when down deep (Boyle's law!), makes the hiatal hernia slide up into the chest too forcefullly resulting in (small) asymptomatic tears that bleed (with it being known that this can happen in Hiatal Hernias in people who do NOT dive!!).

I did a literature and web search, and while there is much literature on SCUBA diving and hiatal hernias, on various web-sites,. including DAN's, I found none that specificly linked heavy-duty diving w/hiatal hernia and active bleeding, though most diving literature strongly recommends to get a large hiatal hernia repaired.

I think I will hold off diving until I had my surgery and healed up in the hope that this will fix the problem permanently.

Thus the purpose with this post is twofold: 1) a tale about how you can be super healthy, an active diver and still possibly become deadly ill because of the diving if you have what otherwise is considered a trivial abnormality and 2) to see if there are any out there in the diving community who may know more about what the pressure difference in the abd and chest, and the air trapped in the stomach vs the air in the lungs that equalize through the reg may be doing as to the displacement of the Hiatal Hernia during the dive and the forces that may be at play.

(not surprisingly, when I was under water, even with the Hct of 20%, I felt good and at peace and at home - my problem was above water where schlepping the tank and equipment almost killed me, certainly knocked the wind out of me!!)

 

[Saturation]

An unusual situation worth some comments.

If your diving caused any laceration to your UGI, which was of insufficient volume to cause hematemesis [blood is a good emetic], you'd notice it as hematochezia. A heme test is considered pathologic unless proven otherwise and can easily be done at home.

Bleeding down from 55->20% is a substantial blood loss and should not be taken lightly.

It is unusual for medical institutions to transfuse a patient to 33%, give Fe then get cleared for diving, that level of replacement is only for sedentary activity so a workup can proceed out of hospital. If baseline was 55%, 33% is insufficient for exertional work since the patient was presumed normal; any form of exertion after a still undiagnosed source of bleeding risks re-initiating bleeding, particularly if there is strong suspicion it could be of mechanical origin.

Hyperoxia from diving compensates for anemia, which suggests bleeding was relatively acute.

Fundoplication often has numerous post op issues that prolong return to normalcy, assuming this is truly the source of bleeding, which can easily be inferred with upper endoscopy.

 

[Canyondreamer]

Clarification:
1.
I was transfused up to 25%, iron (and no bleeding) got me up to 31% over the next 14 days

2.
Guarcs were done repeatedly, and were negative (though I honestly did not do them in the Bahamas!)

3.
Part of the "Million-dollar-work-up" included upper and lower endoscopy (clean as a whistle, no bleeding source - large HH), Barium swallow with follow-through: prestine except for large HH with reflux to half-way up the esophagus), pill camera with no evidence of AV malformation or other bleeding source in the SB.

4.
The only one who initally took the symptoms of the bleeding from 55% to 20 lightly was me, in retrospect obviously appearing studpid, but given the incidiousness of the bleed over 3-6 months with day-to-day up-and down symptoms, and only recognizing the slide down in energy when looking back months, is the only explanation I can give. Once the hct of 20% was seen, trust me, no-one, even myself, took it lightly as I was acutely admitted for transfusion and work-up. Still far from the record. I recently had a patient walk into my office with a hematocrit of 5%!!

5.
Because I am in as good shape as I am, and because the bleeding had to be very slow over months, I was able to do my 12 hour/day work and dive as mentioned - going from 20% to 33% (actually as soon as I got my 4 blood transfusions) I felt great!! - discussed the pros and cons of diving with my internist and gastroenterologist and given the lack of literature for causality, decided (and was OK'ed) to dive - perfectly fine as the dives were fine, but obviously with the possibility of a causality not previously recognized and reported - hence the thread/post!

6.
Yes, I understand about the HH repair and I am not looking forward to the likely month-long "no-diving" post-surgery, but based on published literature there is a 90+% chance that the surgery will fix the problem.

7.
You make me and my physician colleagues sound like idiots - which is OK, and I take ownership of that as far as not getting my anemic symptoms checked out earlier, but not for what happened after I got checked out, where we recognized that whatever had bled was bleeding no more, and again were unable to find literature that showed any causality between diving and a bleeding HH, I don't think anyone is to blame. I was diving comfortably with a Hct of 20%, 33% was "luxury" as far as me feeling completely well w/no anemic symptoms what-so-ever. I have had avid young SCUBA diving patients with i.e. Aplastic Anemia (I am a hem-onc doc - so contrary to what may be clear from my OP, I do know a thing or two about anemia, transfusions and safe hematocrits!) who despite me adamantly telling them not to, routinely dove with platelets in the 10-20K range (lowest 2000) and hematocrits in the 20% range - and consistently lived to tell about it. My hypothesis is that the diving itself is less stressful to the heart and body when anemic than doing normal things above water, as most of us are used to do things leisurely underwater to avoid to the extend possible anything that exerts us in order to minimize our air consumption.

By the way, I told my (university based) G-I doc that if we could find a causality between diving and bleeding from a HH based on pressure differences during the dive - it may be a publishable report as again, we found nothing relating to this when searching.

 

[knotical]

Not a physician, just a diver with a hiatal hernia of long standing. I no longer dive in a head-down position, but otherwise the hernia has had no impact on my diving, or vice-versa as far as I know.

From unrelated diving experience, air in the stomach tends to take care of itself by natural processes. It compresses at depth and sometimes is released during or after ascent by a good old-fashioned belch. I suppose it is possible that a displaced hiatal hernia could block the path of the belch, but if that were happening, I suspect you’d feel discomfort.

And speaking as a scientist, coincidence in time of course does not necessarily mean a causal relationship. I’d explore other lines of reasoning in addition to the possible diving connection, as I’m sure you already are.

Good luck,

k

 

[Saturation]

It reads like you have the skills and facilities to manage these conditions.

I do not know of a published relationship between diving, HH and bleeding, but as knotical suggests, known association between all 3 is aerophagia: it aggravates HHs, aerophagia is common in diving, so its inferred HH can be aggravated by diving [ particularly if gas cannot be relieved quickly enough during ascent].

Lastly, as aggravated HHs bleed, particularly large ones, then it follows diving can aggravate HH bleeding, the key again, is aerophagia.

 

[TSandM]

Hmm . . . as Saturation says, that was a heck of a blood loss; even the second time. To have multiple samples come back guaiac negative is puzzling.

One thing that occurred to me is whether someone who is G6PD deficient would experience hemolysis in the setting of high ppO2s concomitant with diving. I wasn't able to find anything to support this, but it's at least an intriguing concept.

On the other hand, I'm not sure from your post that enough time went by between your transfusions and your trip, to be sure that the subsequent fall in Hct was related to the diving. I guess what will tell is time -- I'd be suspicious of a red cell line myelodysplasia if this happens again (and I'm assuming that your red cell indices were microcytic or normal).

 

[slingshot]

Smear? I presume that a hematologist would have looked, and also that he would have reported any lab features of hemolysis, hence his emphasis on bleeding as a source. Enzymatic defects are always an interesting consideration, especially if you can tie in a comment about fava beans and a nice Chianti! More seriously however, you did not say if the hernia was possibly paraesophageal, which would seem to be more problematic, but in either case you have not accounted for why an HH would be at fault when endoscopy obtained during the worst of your anemia was negative, and while there has been no proof of blood in your stool. A serosal surface tear causing a slow crit drop of 20 points? That seems rather unlikely, but then I'm just a guy posting on the internet, and not representing myself as your physician. Thus, I wonder if the HH and diving are red herrings. Were it me, I would have serious reservations about continuing to travel and dive until this is resolved. Best of luck to you in getting to the bottom of this.

 

[Duke Dive Medicine]

It's been demonstrated that head-up immersion results in a pressure differential between the stomach and esophagus. This is an older reference and maybe you've found it already, but just in case, here it is:

[abstract] GASTROESOPHAGEAL DYNAMICS DURING IMMERSION IN WATER TO THE NECK.

There's no evidence that diving would aggravate a hiatal hernia to the point where it would hemorrhage. You're a heme-onc doc so presumably you've ruled out, or are in the process of ruling out, hematologic abnormalities. You had an 8% drop in hematocrit over four days. If it was going into your GI system you'd have seen evidence of it over and above a positive guaiac. The blood has to be going somewhere. Until you've found out where, diving is contraindicated. Your trip to the Bahamas after being transfused for newly discovered "profound anemia" evidenced by a hematocrit of 20% was probably not advisable, especially when the etiology hadn't been identified.

Diving after a Nissen fundoplication can be problematic. We've encountered this before... sometimes a hiatal hernia repair leaves the patient unable to belch. It sounds simple, but if you can't burp, you can't dive. Saturation alluded to this above; if you ingest any air at pressure and are unable to release it on ascent, you're at risk of disrupting the repair or, worse yet, gastric rupture.

Edit: did your million dollar workup include a chest/abdominal CT?

Best regards,
DDM

 

[Canyondreamer]

Thank you for the many thoughtful replyes, I agree, while suspicious, a causual relationship to diving has not been proven.

The Anemia was/is a classic iron deficiency anemia as one would expecxt to see in someone with occult, slow bleeding: microcytic and with unmeasurable S-Iron and low-low transferrin, moderately low MCH, RDW, RBC and mildly increased retics. All other indices, including white cell counts, diff, pltlc etc were entirely normal, as was the hem-path review of the smear except for the red cell abnormalities. Hemolysis w/u completely negative (hapto nml, LDH nml, Unconj bili nml), thus no evidence for MDS or hemolytic anemia. Could there be a problem w/iron absorption? - perhaps, even though the nice rise in the hct during the 2 weeks on irion therapy would speak against that.

My working hypothesis remains, that the dives somehow sets the stage for (micro?)tears in the EG-junction making for a small bleed, that quickly stops, and with the tears healing in-between the dives explaining the negative work-up 3 weeks after my dive - and the aggregate anemia over months. It is well described that a HH in a non-diver can present as a severe iron deficiency anemia - and it is still possible that this is all it is with me, with my frequent diving making for a classic faulty association bias, though the fact that I was going up in hct pre-dive, and lost points post dive does make me (and my docs) suspicious of some sort of relationship. No testing of stool has (yet) been done right after a dive. I am contemplating the next step with my G-I doc, and as I write this have a second capsule cam endoscopy underway. Following the Hct closely the next weeks goes without saying. Tagged red cell scan may be in the future if still no documented explanation.

I don't like what I hear about the HH repair and the potential for permanently making dives impossible - that would be a serious bummer that I would go to great length to avoid. My docs and myself now aggree that I should not dive until this is sorted out completely. I still maintain with the results as they were pre-Bahama that it was OK to dive. As said repeatedly, the dives went flawless and were very enjoyable, after the dives, new (unexpected) data emerged that should and will give pause in further diving. For those interested, I will keep you posted on how it ends.

 

[TSandM]

Please do . . . This is a very odd case. I am assuming, although you didn't specifically mention it, that you did have a colonoscopy done, since they are contemplating a capsule endoscopy.