Tuesday, September 18, 2007

Heartburn, Hiatal Hernia, and Gastroesophageal Reflux Disease (GERD)

Heartburn, Hiatal Hernia, and Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux disease, or GERD, occurs when the lower esophageal sphincter (LES) does not close properly and stomach contents leak back, or reflux, into the esophagus. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach. The esophagus carries food from the mouth to the stomach.
When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Occasional heartburn is common but does not necessarily mean one has GERD. Heartburn that occurs more than twice a week may be considered GERD, and it can eventually lead to more serious health problems.
Anyone, including infants, children, and pregnant women, can have GERD.
What are the symptoms of GERD?
The main symptoms are persistent heartburn and acid regurgitation. Some people have GERD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GERD can also cause a dry cough and bad breath.
GERD in Children
Studies* show that GERD is common and may be overlooked in infants and children. It can cause repeated vomiting, coughing, and other respiratory problems. Children's immature digestive systems are usually to blame, and most infants grow out of GERD by the time they are 1 year old. Still, you should talk to your child's doctor if the problem occurs regularly and causes discomfort. Your doctor may recommend simple strategies for avoiding reflux, like burping the infant several times during feeding or keeping the infant in an upright position for 30 minutes after feeding. If your child is older, the doctor may recommend avoiding

  1. sodas that contain caffeine
  2. chocolate and peppermint
  3. spicy foods like pizza
  4. acidic foods like oranges and tomatoes
  5. fried and fatty foods
Avoiding food 2 to 3 hours before bed may also help. The doctor may recommend that the child sleep with head raised. If these changes do not work, the doctor may prescribe medicine for your child. In rare cases, a child may need surgery.
*Jung AD. Gastroesophageal reflux in infants and children. American Family Physician. 2001;64(11):1853–1860.
What causes GERD?
No one knows why people get GERD. A Hiatal hernia may contribute. A Hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. The diaphragm helps the LES keep acid from coming up into the esophagus. When a Hiatal hernia is present, it is easier for the acid to come up. In this way, a Hiatal hernia can cause reflux. A Hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.
Other factors that may contribute to GERD include:

  1. alcohol use
  2. overweight
  3. pregnancy
  4. smoking
Also, certain foods can be associated with reflux events, including:

  1. citrus fruits
  2. chocolate
  3. drinks with caffeine
  4. fatty and fried foods
  5. garlic and onions
  6. mint flavorings
  7. spicy foods
  8. tomato-based foods, like spaghetti sauce, chili, and pizza
How is GERD treated?
If you have had heartburn or any of the other symptoms for a while, you should see your doctor. You may want to visit an internist, a doctor who specializes in internal medicine, or a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on how severe your GERD is, treatment may involve one or more of the following lifestyle changes and medications or surgery.
Lifestyle Changes:

  1. If you smoke, stop.
  2. Do not drink alcohol.
  3. Lose weight if needed.
  4. Eat small meals.
  5. Wear loose-fitting clothes.
  6. Avoid lying down for 3 hours after a meal.
  7. Raise the head of your bed 6 to 8 inches by putting blocks of wood under the bedposts—just using extra pillows will not help.
  8. Medications
Your doctor may recommend over-the-counter antacids, which you can buy without a prescription, or medications that stop acid production or help the muscles that empty your stomach.
Antacids, such as:

  1. Alka-Seltzer,
  2. Maalox,
  3. Mylanta,
  4. Pepto-Bismol,
  5. Rolaids, and
  6. Riopan,
are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Many brands on the market use different combinations of three basic salts:

  1. magnesium,
  2. calcium, and
  3. aluminum,
with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, have side effects. Magnesium salt can lead to diarrhea, and aluminum salts can cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.
Calcium carbonate antacids, such as:

  1. Tums,
  2. Titralac, and
  3. Alka-2,
can also be a supplemental source of calcium. They can cause constipation as well.
Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux. These drugs may help those who have no damage to the esophagus.
H2 blockers, such as:

  1. cimetidine (Tagamet HB),
  2. famotidine (Pepcid AC),
  3. nizatidine (Axid AR), and
  4. ranitidine (Zantac 75),
impede acid production. They are available in prescription strength and over the counter. These drugs provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few weeks at a time. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton pump inhibitor.
Proton pump inhibitors include:

  1. omeprazole (Prilosec),
  2. lansoprazole (Prevacid),
  3. pantoprazole (Protonix),
  4. rabeprazole (Aciphex), and
  5. esomeprazole (Nexium),
which are all available by prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD.
Another group of drugs, prokinetics, helps strengthen the sphincter and makes the stomach empty faster. This group includes:

  1. bethanechol (Urecholine) and
  2. metoclopramide (Reglan).
Metoclopramide also improves muscle action in the digestive tract, but these drugs have frequent side effects that limit their usefulness.
Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, while the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your doctor is the best source of information on how to use medications for GERD.
What if symptoms persist?
If your heartburn does not improve with lifestyle changes or drugs, you may need additional tests.


  1. A barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the esophagus. With this test, you drink a solution and then x rays are taken. Mild irritation will not appear on this test, although narrowing of the esophagus—called stricture—ulcers, hiatal hernia, and other problems will.
  2. Upper endoscopy is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor's office. The doctor will spray your throat to numb it and slide down a thin, flexible plastic tube called an endoscope. A tiny camera in the endoscope allows the doctor to see the surface of the esophagus and to search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD. The doctor may use tiny tweezers (forceps) in the endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal damage caused by acid reflux and rule out other problems if no infecting organisms or abnormal growths are found.
  3. In an ambulatory pH monitoring examination, the doctor puts a tiny tube into the esophagus that will stay there for 24 hours. While you go about your normal activities, it measures when and how much acid comes up into your esophagus. This test is useful in people with GERD symptoms but no esophageal damage. The procedure is also helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux.
Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.
Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for GERD. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.
This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. To perform the fundoplication, surgeons use small instruments that hold a tiny camera. Laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. When performed by experienced surgeons, the procedure is reported to be as good as standard fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.
In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn:

  1. The Bard EndoCinch system puts stitches in the LES to create little pleats that help strengthen the muscle.
  2. The Stretta system uses electrodes to create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen the muscle. The long-term effects of these two procedures are unknown.

Recently the FDA approved an implant that may help people with GERD who wish to avoid surgery. Enteryx is a solution that becomes spongy and reinforces the LES to keep stomach acid from flowing into the esophagus. It is injected during endoscopy. The implant is approved for people who have GERD and who require and respond to proton pump inhibitors. The long-term effects of the implant are unknown.

What are the long-term complications of GERD?
Sometimes GERD can cause serious complications. Inflammation of the esophagus from stomach acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett's esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer.
Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by GERD.

For information about Barrett's esophagus, please see the Barrett's Esophagus fact sheet from the National Institute of Diabetes and Digestive and Kidney Diseases.

Points to Remember

  1. Heartburn, also called acid indigestion, is the most common symptom of GERD. Anyone experiencing heartburn twice a week or more may have GERD.
  2. You can have GERD without having heartburn. Your symptoms could be excessive clearing of the throat, problems swallowing, the feeling that food is stuck in your throat, burning in the mouth, or pain in the chest.
  3. In infants and children, GERD may cause repeated vomiting, coughing, and other respiratory problems. Most babies grow out of GERD by their first birthday.
  4. If you have been using antacids for more than 2 weeks, it is time to see a doctor. Most doctors can treat GERD. Or you may want to visit an internist—a doctor who specializes in internal medicine—or a gastroenterologist—a doctor who treats diseases of the stomach and intestines.
  5. Doctors usually recommend lifestyle and dietary changes to relieve heartburn. Many people with GERD also need medication. Surgery may be an option.

Hope Through Research
No one knows why some people who have heartburn develop GERD. Several factors may be involved, and research is under way on many levels. Risk factors—what makes some people get GERD but not others—are being explored, as is GERD's role in other conditions such as asthma and bronchitis.


The role of hiatal hernia in GERD continues to be debated and explored. It is a complex topic because some people have a hiatal hernia without having reflux, while others have reflux without having a hernia.

Much research is needed into the role of the bacterium Helicobacter pylori. Our ability to eliminate H. pylori has been responsible for reduced rates of peptic ulcer disease and some gastric cancers. At the same time, GERD, Barrett's esophagus, and cancers of the esophagus have increased. Researchers wonder whether having H. pylori helps prevent GERD and other diseases. Future treatment will be greatly affected by the results of this research.

For More Information
American College of Gastroenterology (ACG)
4900-B South 31st Street
Arlington, VA 22206–1656
Phone: 703–820–7400
Fax: 703–931–4520
Internet: http://www.acg.gi.org/

American Gastroenterological Association (AGA)
National Office
4930 Del Ray Avenue
Bethesda, MD 20814
Phone: 301–654–2055
Fax: 301–652–3890
Email: webinfo@gastro.org
Internet: http://www.gastro.org/ ..

International Foundation for Functional Gastrointestinal Disorders (IFFGD) Inc.
P.O. Box 170864
Milwaukee, WI 53217–8076
Phone: 1–888–964–2001 or 414–964–1799
Fax: 414–964–7176
Email: iffgd@iffgd.org
Internet: http://www.aboutgerd.org/
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)
P.O. Box 6
Flourtown, PA 19031
Phone: 215–233–0808
Fax: 215–233–3939
Email: naspghan@naspghan.org
Internet: http://www.naspghan.org/
Pediatric/Adolescent Gastroesophageal Reflux Association Inc. (PAGER)
P.O. Box 1153
Germantown, MD 20875–1153
Phone: 301–601–9541
Email: gergroup@aol.com
Internet: http://www.reflux.org/
The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, this does not mean or imply that the product is unsatisfactory.
National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892–3570
Email: http://digestive.niddk.nih.gov/about/contact.htm

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publication was reviewed by G. Richard Locke, M.D., Mayo Clinic; and Joel Richter, M.D., Cleveland Clinic Foundation.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.
NIH Publication No. 03–0882June 2003

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Hiatus hernia (Hiatal hernia)

Hiatus hernia
From Wikipedia, the free encyclopedia
(Redirected from Hiatal hernia)

Classification & external resources

K44., Q40.1
553.3, 750.6
med/1012 radio/337

Hiatal Hernia

A hiatus hernia or hiatal hernia is the protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.

The symptoms include acid reflux, and pain, similar to heartburn, in the chest and upper stomach.

In most patients, hiatus hernias cause no symptoms. Sometimes patients experience heartburn and regurgitation, when stomach acid refluxes back into the esophagus.

The following are possible causes or contributing factors for having a hiatus hernia:
Frequent coughing
Straining with constipation
Frequent bending over or heavy lifting


Upper GI endoscopy depicting hiatus hernia.

The diagnosis of a hiatus hernia is typically made through an upper GI series or endoscopy.

There are two major kinds of hiatus hernia and perhaps a third:

  • The most common (95%) is the sliding hiatus hernia, where the gastroesophageal junction moves above the diaphragm together with some of the stomach.
  • The second kind is rolling (or paraesophageal) hiatus hernia, when a part of the stomach herniates through the esophageal hiatus beside, and without movement of, the gastroesophageal junction. It is about 100 times less common than the first kind. [1]
  • A third kind is also sometimes described, and is a combination of the first and second kinds.

In most cases, sufferers experience no discomfort and no treatment is required. However, when the hiatal hernia is large, or is of the paraesophageal type, it is likely to cause esophageal stricture and discomfort. Symptomatic patients should elevate the head of their beds and avoid lying down directly after meals until treatment is rendered. If the condition has been brought on by stress, stress reduction techniques may be prescribed, or if overweight, weight loss may be indicated. Medications that lower the lower esophageal sphincter (or LES) pressure should be avoided. Antisecretory drugs like proton pump inhibitors and H2 receptor blockers can be used to reduce acid secretion.

Where hernia symptoms are severe and chronic acid reflux is involved, surgery is sometimes recommended, as chronic reflux can severely injure the esophagus and even lead to esophageal cancer.

The surgical procedure used is called Nissen fundoplication. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. The procedure is now commonly performed laparoscopically. With proper patient selection, laparoscopic fundoplication has low complication rates and a quick recovery.[2]
Complications include gas bloat syndrome, dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia. The procedure sometimes fails over time, requiring a second surgery to make repairs.

A hiatus hernia per se does not cause any symptoms. The condition promotes reflux of gastric contents (via its direct and indirect actions on the anti-reflux mechanism) and thus is associated with gastroesophageal reflux disease (GERD). In this way a hiatus hernia is associated with all the potential consequences of GERD - heartburn, esophagitis, Barrett's esophagus and esophageal cancer. However the risk attributable to the hiatus hernia is difficult to quantify, and at most is low.

Besides discomfort from GERD and dysphagia, hiatal hernias can have severe consequences for patients if not treated. While sliding hernias are primarily associated with gastroesophageal acid reflux, rolling hernias can strangulate a portion of the stomach above the diaphragm. This strangulation can result in esophageal or GI tract obstruction and the tissue even become ischemic and necrose.

Another severe complication, although very rare, is a large herniation that can restrict the inflation of a lung, causing pain and breathing problems.

Hiatus hernias affect anywhere from 1 to 20% of the population.[citation needed] Of these, 9% are symptomatic, depending on the competence of the lower esophageal sphincter (LES). 95% of these are "sliding" hiatus hernias, in which the LES protrudes above the diaphragm along with the stomach, and only 5% are the "rolling" type (paraesophageal), in which the LES remains stationary but the stomach protrudes above the diaphragm. People of all ages can get this condition, but it is more common in older people.

Notes and references
^ Lawrence, P. (1992). Essentials of General Surgery. Baltimore: Williams & Wilkins.
^ Lange CMDT 2006

External links
01011 at CHORUS

vdeHealth science - Medicine - Digestive system - Gastroenterology (primarily K20-K93, 530-579)

GERD - Achalasia - Boerhaave syndrome - Zenker's diverticulum - Mallory-Weiss syndrome - Barrett's esophagus - Esophageal cancer - Esophageal varices

Gastric ulcer - Non-ulcer dyspepsia - Gastroparesis - Pyloric stenosis - Malabsorption (e.g. celiac disease, giardiasis) - Stomach cancer

Small intestine
Duodenal ulcer - Intussusception - Malabsorption (e.g. coeliac, lactose intolerance, fructose malabsorption, Whipple's) - Abdominal angina

Diarrhea - Appendicitis - Bowel obstruction - Diverticulitis - Diverticulosis - IBD (Crohn's, Ulcerative colitis) - IBS - Constipation - Megacolon (Toxic megacolon) - Anal fissure - Anal fistula - Anal abscess - Rectal prolapse

Inguinal (Indirect, Direct) - Femoral - Umbilical - Incisional - Diaphragmatic - Hiatus

Alcoholic liver disease - Cholestasis - Liver failure - Cirrhosis - Hepatitis - PBC - NASH - Fatty liver - Peliosis hepatis - Portal hypertension - Hepatorenal syndrome - Budd-Chiari - Hepatocellular carcinoma

Accessory digestive
Gallbladder/Biliary tree (Gallstones, Choledocholithiasis, Cholecystitis, Cholangitis, PSC, Biliary fistula, Ascending cholangitis) - Pancreas (Acute pancreatitis, Chronic pancreatitis, Pancreatic pseudocyst, Hereditary pancreatitis, Pancreatic cancer)

Tropical sprue - Hematemesis - Melena - Gastrointestinal bleeding (Upper, Lower) - Peritonitis
See also congenital

vdeCongenital malformations and deformations of digestive system (Q35-Q45, 749-751)

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From Wikipedia, the free encyclopedia

Classification & external resources

Esophagitis (or Oesophagitis) is inflammation of the esophagus.

The most common cause is gastroesophageal reflux disease (GERD). If caused by GERD, the diseases is also called reflux esophagitis.

Other causes of esophagitis include:

External links
Esophageal disorders The Merck Manual entry for Esophageal disorders.

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Nissen fundoplication
From Wikipedia, the free encyclopedia

Nissen fundoplication is an elective surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure. Partial fundoplications known as a Dor fundoplication or Toupet fundoplication may accompany surgery for achalasia.

The procedure
In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, restoring the function of the lower esophageal sphincter. This prevents the reflux of gastric acid (in GERD) and/or the sliding of the fundus through the enlarged esophageal hiatus in the diaphragm. In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped all the way around the esophagus.
Surgery for achalasia is generally accompanied by either a Dor or Toupet partial fundoplication. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus. In a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus.
The procedure is often done laparoscopically. When used as a method to alleviate gastroesophageal reflux symptoms in patients with delayed gastric empyting, this procedure is frequently done in conjunction with modification of the pylorus via pyloromyotomy or pyloroplasty.

Nissen fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1%. Studies have shown that after 10 years, 89.5% of patients are still symptom-free.[1]

Complications include gas bloat syndrome, dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia.[2] The procedure can also become undone over time in about 5-10% of cases, leading to recurrence of the symptoms. If the symptoms warrant repeated surgery, the surgeon may use Marlex or another form of artificial mesh to strengthen the connection.[3]

belch, leading to an accumulation of gas in the stomach or small intestine. This is said to occur in 2-5% of patients, depending on surgical technique, and is commonly believed to be related to the tightness of the "wrap". Most often, gas bloat syndrome is self-limiting within 2 to 4 weeks, but in some it may persist. The offending gas may come from dietary sources (especially carbonated beverages). Another suspected cause is subconscious swallowing of air (aerophagia). If gas bloat syndrome occurs post operatively and does not resolve with time, dietary restrictions, or counselling regarding aerophagia, it may be beneficial to consider treating the condition with an endoscopic balloon dilitation.[citation needed]

Dr. Rudolph Nissen first performed the procedure in 1955, and published the results of two cases in a 1956 Swiss Medical Weekly.[4] In 1961 he published a more detailed overview of the procedure.[5] Nissen originally called the surgery gastroplication, but the procedure has borne his name since it gained popularity in the 1970's.[6]

^ Minjarez, RC; Jobe BA. "Surgical therapy for gastroesophageal reflux disease". GI Motility online. DOI:10.1038/gimo56.
^ Waring JP (1999). "Postfundoplication complications. Prevention and management". Gastroenterol. Clin. North Am. 28 (4): 1007-19, viii-ix. PMID 10695014.
^ Curet MJ, Josloff RK, Schoeb O, Zucker KA (1999). "Laparoscopic reoperation for failed antireflux procedures". Archives of surgery 134 (5): 559-63. PMID 10323431.
^ Nissen R (1956). "[A simple operation for control of reflux esophagitis.]" (in German). Schweizerische medizinische Wochenschrift 86 (Suppl 20): 590-2. PMID 13337262.
^ Nissen R (1961). "Gastropexy and "fundoplication" in surgical treatment of hiatal hernia". The American journal of digestive diseases 6: 954-61. PMID 14480031.
^ Stylopoulos N, Rattner DW (2005). "The history of hiatal hernia surgery: from Bowditch to laparoscopy". Ann. Surg. 241 (1): 185-93. PMID 15622007.

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