Patient Information Gastroesophageal Reflux Disease (Hiatal Hernia and Heartburn)

PATIENT INFORMATION
GASTROESOPHAGEAL REFLUX DISEASE (Hiatal Hernia

and Heartburn)
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 the 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 long-term complications.
WHAT IS GASTROESOPHAGEAL REFLUX?
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 tube
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 hiatal hernia may weaken the LES and causes
reflux. Hiatal hernia occurs when the upper part of the stomach moves up
into the chest through a small opening in the diaphragm. 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 can 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, it may be
present in patients with severe GERD or esophagitis (inflammation of the
esophagus).
Last Updated 9/24/2009
WHAT OTHER FACTORS CONTRIBUTE TO GERD?

Dietary and lifestyle choices may contribute to GERD. Certain
foods and beverages, including chocolate, peppermint, fried or
fatty foods, coffee, tomato sauce, citrus juices (like orange
juice) 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.
Also, certain medication can weaken the LES pressure.
WHAT DOES HEARTBURN/GERD 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.
The burning, 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.
Heartburn 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.
Occasionally, GERD may present only with nausea or frequent
belching with the classic burning pain.
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
percent of pregnant women experience daily heartburn and
more than 50 percent 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 to thrive.
WHAT IS THE TREATMENT FOR GERD?
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 materials.
1. Avoiding certain foods and beverages : These foods include
chocolate, peppermint, fatty foods,
coffee, soda (and all carbonated drinks) and alcoholic
beverages. Foods and beverages that can irritate a
damaged esophageal lining, such as citrus fruits
(particular orange juice) and juices, tomato products,
spicy food and pepper, should also be avoided. Antiinflammatories like aspirin, ibuprofen (Advil, Motrin) and
naprosyn (Aleve) should also be avoided.
2. Meals: Decreasing the size of portions at mealtime may
also help control symptoms. Eating meals at lest 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.
3. Stop Smoking.
4. Elevating the head of the bed: Elevate your bed 6-inch
blocks or sleeping on a specially designed wedge reduces
heartburn by allowing gravity to minimize reflux of stomach
contents into the esophagus.
5. Medications: 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. 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
consulted.
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 (Tagamet HB), famotidine (Pepcid
AC), and ranitidine (Zantac 75,150). These are best taken
before bedtime. Another type of drug, the proton pump (or
acid pump) inhibitor may be necessary. These are more
potent than H2 blockers and best taken in the morning
ON AN EMPTY STOMACH. Currently there are five
available: omeprazole (Prilosec OTC), esomeprzole
(Nexium), lansoprazole (Prevacid), pantoprazole (Protonix)
and rabeprazole (Achiphex)
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 and
metoclopramide or erythromycin.
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 tissues 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.
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 and have failed.
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 Barretts esophagitis which is severe
damage to the skin-like lining of the esophagus. Doctors
believe this condition may be a precursor to esophageal
cancer.

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PATIENT INFORMATION

GASTROESOPHAGEAL REFLUX DISEASE (Hiatal Hernia

Last Updated 9/24/2009

WHAT OTHER FACTORS CONTRIBUTE TO GERD?

previously recognized and may produce recurrent vomiting,

Other approaches to therapy will increase the strength of the LES

WHAT IF SYMPTOMS PERSIST?

Esophageal manometric studies - pressure measurements

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