Heartburn, also known as gastroesophageal reflux disease or GERD, is a very common condition. For most people, it is a mild problem that rarely requires medication. For some, however, it is a serious and even debilitating problem that can significantly affect quality of life. GERD is often due to malfunction of the valve between the esophagus and stomach (the lower esophageal sphincter or LES) and/or a hiatal hernia.
The chest is separated from the abdomen by a dome-shaped sheet of muscle called the diaphragm. The esophagus passes through an opening in the diaphragm called the hiatus. When the tissue around the hiatus weakens, part of the stomach may protrude through the opening into the chest cavity, which is a hiatal hernia. Weakening of the anchoring tissues of the gastroesophageal junction leads to a hiatal hernia. Hiatal hernias are very common and small hiatal hernias may produce no symptoms.
Typical symptoms include heartburn and regurgitation when stomach acid refluxes back up into the esophagus. Some patients may experience esophagitis (damage to the lining of the esophagus). Bleeding caused by this damage may lead to anemia. A stricture, or narrowing, of the esophagus may occur and can make swallowing difficult. Respiratory symptoms such as asthma, chronic cough, bronchitis, or recurring pneumonia can also be caused by GERD. Chronic damage to the esophagus can lead to Barrett’s esophagus, a precancerous condition, or even to cancer. Very large hiatal hernias can be dangerous because there is a risk that the stomach can become twisted or obstructed.
Diagnosis of a hiatal hernia may be made by endoscopy, barium swallow x-ray or CT scan. Endoscopy is done to evaluate the extent of damage to the esophagus and to look for other conditions. Pressure measurements (esophageal manometry) are done to evaluate the function of the esophagus. In some cases, a probe is placed (24-hour pH study) to measure the amount and frequency of acid reflux into the esophagus.
Treatment is called for when GERD causes bothersome symptoms or when a hiatal hernia has become large. Mild GERD can be controlled with lifestyle changes, such as avoiding things that cause reflux (tobacco, fatty foods, alcohol, caffeine, chocolate, peppermint, and spearmint); eating smaller, more frequent meals, and not eating within 4 hours of bedtime; avoiding bending, stooping, sit-ups, and tight clothing; losing weight; and elevating the head of the bed 6-8″ with blocks.
Medications can also help control the symptoms of GERD if lifestyle changes are inadequate. They include antacids such as Tums and Mylanta, acid-blocking drugs such as Zantac, Tagamet, or Pepcid (“H2 blockers”) or Prilosec, Prevacid, and Nexium (proton pump inhibitors or “PPI’s”). Some of these medications may have significant side effects with short or long term use.
Patients who do not respond well to medical therapy, who do not wish to take medication for the rest of their lives, or who have large hiatal hernias may benefit from surgery. This is known as fundoplication and hiatal hernia repair. This procedure involves creating a new valve by wrapping the upper portion of the stomach around the lower esophagus and repairing the hiatal hernia. It is most commonly done with a technique called laparoscopic fundoplication, in which the surgery is done through small incisions with the help of a camera.