Q:An acquaintance of mine has for quite some time been taking Gaviscon for hiatus hernia. Eight years ago, she stopped taking benzodiazepines after 17 years.

I understand that Gaviscon is similar to Zantac but milder. Are there any known side effects, as there is a likelihood that these are not doing her very much good.

The lady's mother, also taking Gaviscon, became ill recently with sickness and diarrhea, and these I note are among the side effects of Zantac. Your help would be much appreciated. MS, Nottingham.........

A:As you no doubt know, a hiatus hernia occurs when a portion of the stomach wall protrudes through the opening of the diaphragm, called the "hiatus", through which food passes from the esophagus and into the stomach. Ordinarily, this opening has a ring of muscles like our sphincter muscles, opening to allow food to drop into the stomach and closing to avoid the contents of the stomach from heading backward. When this muscle is weakened, it doesn't close as effectively as it should. The result is backing up, or "reflux" of this acidic stomach acid through the esophagus.

The result is quite a painful, burning sensation, since the esophagus does not have the stomach's natural protection against digestive acids. Sometimes patients suffer chest pain so severe that it's confused with a heart attack. Pain appears to be worse when the person bends over or lies down, which is when it is easier for the acid to back up.

This condition can also produce heart flutterings or palpitations, vomiting or even blood in the stools, causing it to be often confused with stomach cancer.

Left untreated, a hiatus hernia can enlarge so much that it can cause a problem breathing. Cases of emphysema have been reported (Rev Esp De Anes y Ranimac, 1996; 43: 76-7). It can also have other, potentially fatal complications, occasionally trapping the colon or spleen (Surgery, 1994; 115: 653-5).

The rest of the hiatus hernia population with no symptoms other than heartburn probably make up the bulk of the body of people sometimes estimated at half the population who pop antacids after eating, complaining that a number of foods "fight back" (Abdominal Imaging, 1993; 18: 7-9).

People who eventually develop a hiatal hernia start out by having difficulty digesting fatty or fried foods. Often they experience nausea, constipation, constant burping, a feeling of indigestion after meals and light stools. Many people will go on to develop gallstones. Ignoring this problem or attempting to ease it with over the counter antacids oftentimes can progress to gastritis or an ulcer (Townsend Letter for Doctors & Patients, November 1996: 95). Patients with long standing hiatal hernias also can have severe iron deficiency anemia (Am J Gastroenterology, 1992; 87: 622-6).

Usually, the first line of treatment is long term use of a drug, principally antacid or reflux suppressants. One of the most popular antacids is Gaviscon, which is given to control acid reflux and accompanying heartburn. According to its manufacturer, Gaviscon suppresses the acid reflux by reacting with gastric acid to form a floating thick gel of a neutral stomach ph, which neutralizes stomach acid and impedes reflux. Sometimes the gel itself will be refluxed into the esophagus, where it supposedly forms a protective film over the inflamed tissue there. The drug is made up of sodium bicarbonate, calcium carbonate, aluminium hydroxide gel and magnesium trisilicate, plus artificial sweeteners.

Although generally well tolerated, the chief side effect of this drug is constipation or diarrhea, particularly if taken in large quantities. It also should be used with caution in patients with kidney dysfunction, and patients on a sodium restricted diet should note the high sodium content of the tablets. But the biggest problem with antacids is that they perpetuate the problem. Neutralizing stomach acid only causes the stomach to produce more, which means you continue to take the stuff indefinitely. It also tends to reduce the availability of digestive enzymes, so that you don't digest your food as well as you should.

For all that, antacids generally have fewer side effects than the newer generation of anti reflux drugs (or histamine-2 receptor antagonists, as they're formally known) like ranitidine (Zantac) and omeprazole (Losec). H2 blockers are known to cause insomnia, depression, blurred vision, severe headaches, irregular heartbeat, nausea and vomiting, diarrhea, hepatitis and other liver disorders and, rarely, impotence or blood disorders. Omeprazole can cause chest pain, liver failure, mental disturbances, stomach pain and, again, nausea and vomiting.

Doctors would have you believe there is nothing for this condition but drugs or surgery. But keep reading for some good lifestyle alternatives.