Gastroesophageal Reflux Disease

Peter J. Lydon, MD, FACS

(GERD) Heartburn and Hiatus Hernia

In recent years there has been a profound increase in both the number of people suffering from heartburn and the severity and duration of their suffering. Why this has happened is unknown. That the phenomenon exists is unquestioned and the extensive drug industry advertising for “over the counter medications” to treat heartburn is an indication of how big a problem this has become.

Heartburn is a common term. What does it mean? Usually it is used to describe a burning sensation in the middle of the chest just behind the sternum or breastbone. This is where the heart is located but heartburn has nothing to do with the heart. The burning or pain originates in the esophagus which is behind the heart. The esophagus is a long muscular tube which propels food from the mouth to the stomach. This requires coordinated sequential tightening and relaxing of segments of the esophagus (peristalsis). Normally there is an area at the junction of the esophagus and stomach where the muscles are generally tight, relaxing only temporarily to allow swallowed food to pass into the stomach. This area is called the lower esophageal sphincter (LES). The LES prevents acid, which is produced in the stomach to help digest food, from being pushed, or refluxing, into the esophagus. Human stomachs have a special lining which is resistant to the acid produced in the stomach. On the other hand, the lining of the esophagus has no special resistance and is easily “burned” by this acid. The scientific, or medical term, for heartburn is gastroesophageal reflux disease (GERD).

Anyone might have occasional brief episodes of heartburn. This is considered normal. It is abnormal when it happens several times during 24 hours, when it happens many times a month, and when it begins to cause swallowing difficulties, hoarseness, coughing episodes, or bleeding. When the acid only goes as high as the middle of the esophagus it usually is felt as heartburn. It can however go as high as the mouth where some people will get a sour or acid taste. If the acid does get as high as the mouth it can flow into the larynx or voice box or even further down into the trachea or wind pipe. Frequent irritation of the larynx by acid may cause laryngitis or hoarseness and irritation of the trachea may cause a nagging cough. Generally the hoarseness or cough develop without any pain.

In some people the LES becomes weak. Why this happens is not known. When it happens the normal barrier preventing stomach acid from getting into the esophagus is lost. As acid continues to irritate or burn the lower esophagus there is less peristalsis in that portion of the esophagus. This allows the acid to stay in contact longer with the lining of the esophagus causing more severe burning. Eventually scarring develops where the lining has been repeatedly burned. The scarring may affect nerves in the area and the pain or heartburn may be felt less. Continued scarring leads to narrowing of the lower esophagus known as a stricture. Once a stricture develops food begins to stick in the lower esophagus. Initially, strictures can be widened by passing increasingly larger diameter dilators through them. As time goes on the strictures may become strong and it becomes more dangerous to dilate them. Sometimes the burning of the lining is so severe that ulceration of the lining develops and this may lead to immediate bleeding as well as later scarring.

Many patients with GERD also have a hiatus hernia. That is when a portion of the stomach, normally totally within the abdomen or belly, slides up into the chest. Having a hiatus hernia does not mean you will also have GERD. Most people with hiatus hernias do not have GERD. Unlike inguinal or groin hernias, hiatal hernias often do not have to be repaired.