(Hiatal Hernia and
Gastroesophageal reflux disease (GERD) is a
digestive disorder that affects the lower esophageal sphincter (LES)—the
muscle connecting the esophagus with the stomach. Many people, including
pregnant women, suffer from heartburn or acid indigestion caused by GERD.
Doctors believe that some people suffer from GERD due to a condition called
hiatal hernia. In most cases, heartburn can be relieved through diet and
lifestyle changes; however, some people may require medication or surgery. This
fact sheet provides information on GERD-its causes, symptoms, treatment, and
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 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. The severity of GERD depends on LES
dysfunction as well as the type and amount of fluid brought up from the stomach
and the neutralizing effect of saliva.
What Is the Role of Hiatal Hernia?
Some doctors believe a hiatal hernia
may weaken the LES and cause reflux. Hiatal hernia occurs when the upper part of
the stomach moves up into the chest through a small opening in the diaphragm
(diaphragmatic hiatus). The diaphragm is the muscle separating the stomach from
the chest. Recent studies show that the opening in the diaphragm acts as an
additional sphincter around the lower end of the esophagus. Studies also show
that hiatal hernia results in retention of acid and other contents above this
opening. These substances can reflux easily into the esophagus.
Coughing, vomiting, straining, or sudden
physical exertion can cause increased pressure in the abdomen resulting in
hiatal hernia. Obesity and pregnancy also contribute to this condition. Many
otherwise healthy people age 50 and over have a small hiatal hernia. Although
considered a condition of middle age, hiatal hernias affect people of all ages.
Hiatal hernias usually do not require
treatment. However, treatment may be necessary if the hernia is in danger of
becoming strangulated (twisted in a way that cuts off blood supply, i.e.,
paraesophageal hernia) or is complicated by severe GERD or esophagitis
(inflammation of the esophagus). The doctor may perform surgery to reduce the
size of the hernia or to prevent strangulation.
What Other Factors Contribute to
Dietary and lifestyle choices
may contribute to GERD. Certain foods and beverages, including chocolate,
peppermint, fried or fatty foods, coffee, or alcoholic beverages, may weaken the
LES causing reflux and heartburn. Studies show that cigarette smoking relaxes
the LES. Obesity and pregnancy can also cause GERD.
What Does Heartburn Feel Like?
Heartburn, also called acid
indigestion, is the most common symptom of GERD and usually feels like a burning
chest pain beginning behind the breastbone and moving upward to the neck and
throat. Many people say it feels like food is coming back into the mouth leaving
an acid or bitter taste.
pressure, or pain of heartburn can last as long as 2 hours and is often worse
after eating. Lying down or bending over can also result in heartburn. Many
people obtain relief by standing upright or by taking an antacid that clears
acid out of the esophagus.
pain can be mistaken for the pain associated with heart disease or a heart
attack, but there are differences. Exercise may aggravate pain resulting from
heart disease, and rest may relieve the pain. Heartburn pain is less likely to
be associated with physical activity.
How Common Is Heartburn?
More than 60 million American adults
experience Gerd and heartburn at least once a month, and about 25 million adults
suffer daily from heartburn. Twenty-five% of pregnant women experience daily
heartburn, and more than 50% have occasional distress. Recent studies show that
GERD in infants and children is more common than previously recognized and may
produce recurrent vomiting, coughing and other respiratory problems, or failure
What Is the Treatment
Doctors recommend lifestyle
and dietary changes for most people with GERD. Treatment aims at decreasing the
amount of reflux or reducing damage to the lining of the esophagus from refluxed
Avoiding foods and
beverages that can weaken the LES is recommended. These foods include chocolate,
peppermint, fatty foods, coffee, and alcoholic beverages. Foods and beverages
that can irritate a damaged esophageal lining, such as citrus fruits and juices,
tomato products, and pepper, should also be avoided.
Decreasing the size of portions at
mealtime may also help control symptoms. Eating meals at least 2 to 3 hours
before bedtime may lessen reflux by allowing the acid in the stomach to decrease
and the stomach to empty partially. In addition, being overweight often worsens
symptoms. Many overweight people find relief when they lose weight.
Cigarette smoking weakens the LES.
Therefore, stopping smoking is important to reduce GERD symptoms.
Elevating the head of the bed on
6-inch blocks or sleeping on a specially designed wedge reduces heartburn by
allowing gravity to minimize reflux of stomach contents into the esophagus.
Antacids taken regularly can
neutralize acid in the esophagus and stomach and stop heartburn. Many people
find that nonprescription antacids provide temporary or partial relief. An
antacid combined with a foaming agent such as alginic acid helps some people.
These compounds are believed to form a foam barrier on top of the stomach that
prevents acid reflux from occurring.
Long-term use of antacids, however,
can result in side effects, including diarrhea, altered calcium metabolism (a
change in the way the body breaks down and uses calcium), and buildup of
magnesium in the body. Too much magnesium can be serious for patients with
kidney disease. If antacids are needed for more than 3 weeks, a doctor should be
For chronic reflux and
heartburn, the doctor may prescribe medications to reduce acid in the stomach.
These medicines include H2 blockers, which inhibit acid secretion in the
stomach. Currently, four H2 blockers are available: cimetidine, famotidine,
nizatidine, and ranitidine. Another type of drug, the proton pump (or acid pump)
inhibitor omeprazole inhibits an enzyme (a protein in the acid-producing cells
of the stomach) necessary for acid secretion. The acid pump inhibitor
lansoprazole is currently under investigation as a new treatment for GERD.
Other approaches to therapy will
increase the strength of the LES and quicken emptying of stomach contents with
motility drugs that act on the upper gastrointestinal (GI) tract. These drugs
include cisapride, bethanechol, and metoclopramide.
Tips To Control Heartburn
1. Avoid foods and beverages that affect LES
pressure or irritate the esophagus lining, including fried and fatty foods,
peppermint, chocolate, alcohol, coffee, citrus fruit and juices, and tomato
2. Lose weight if overweight.
3. Stop smoking.
4. Elevate the head of the bed 6 inches.
5. Avoid lying down 2 to 3 hours after eating.
6. Take an antacid.
What If Symptoms Persist?
People with severe, chronic esophageal
reflux or with symptoms not relieved by the treatment described above may need
more complete diagnostic evaluation. Doctors use a variety of tests and
procedures to examine a patient with chronic heartburn.
An upper GI series may be performed
during the early phase of testing. This test is a special x-ray that shows the
esophagus, stomach, and duodenum (the upper part of the small intestine). While
an upper GI series provides limited information about possible reflux, it is
used to rule out other diagnoses, such as peptic ulcers.
Endoscopy is an important procedure
for individuals with chronic GERD. By placing a small lighted tube with a tiny
video camera on the end (endoscope) into the esophagus, the doctor may see
inflammation or irritation of the tissue lining the esophagus (esophagitis). If
the findings of the endoscopy are abnormal or questionable, biopsy (removing a
small sample of tissue) from the lining of the esophagus may be helpful.
The Bernstein test (dripping a mild
acid through a tube placed in the mid-esophagus) is often performed as part of a
complete evaluation. This test attempts to confirm that the symptoms result from
acid in the esophagus. Esophageal manometric studies-pressure measurements of
the esophagus-occasionally help identify critically low pressure in the LES or
abnormalities in esophageal muscle contraction.
For patients in whom diagnosis is
difficult, doctors may measure the acid levels inside the esophagus through pH
testing. Testing pH monitors the acidity level of the esophagus and symptoms
during meals, activity, and sleep. Newer techniques of long-term pH monitoring
are improving diagnostic capability in this area.
Does GERD Require Surgery?
A small number of people with GERD may
need surgery because of severe reflux and poor response to medical treatment.
Fundoplication is a surgical procedure that increases pressure in the lower
esophagus. However, surgery should not be considered until all other measures
have been tried.
What Are the
Complications of Long-Term GERD?
Sometimes GERD results in serious
complications. Esophagitis can occur as a result of too much stomach acid in the
esophagus. Esophagitis may cause esophageal bleeding or ulcers. In addition, a
narrowing or stricture of the esophagus may occur from chronic scarring. Some
people develop a condition known as Barrett's esophagus, which is severe damage
to the skin-like lining of the esophagus. Doctors believe this condition may be
a precursor to esophageal cancer.
Although GERD can limit daily
activities and productivity, it is rarely life-threatening. With an
understanding of the causes and proper treatment most people will find relief.