Gastroesphageal Reflux Disease (GERD) & Hiatal Hernia

• • Heartburn, often worse on recumbency

  • Regurgitation

  • Sliding hiatal hernia on upper GI series

  • Endoscopic biopsy evidence of esophagitis

  • Decreased resting pressure in lower esophageal sphincter

  • Abnormal esophageal acid exposure on prolonged pH monitoring

Epidemiology

• • Most patients (80%) with GERD have a sliding hiatal hernia (type I) in which the gastroesophageal junction (GEJ) is displaced upward into the posterior mediastinum, exposing the lower esophageal sphincter to intrathoracic pressure, which is less than intra-abdominal pressure

  • The principal barrier to reflux is the lower esophageal sphincter, the competence of which is a function of sphincter pressure, sphincter length, and the length exposed to intra-abdominal pressure

  • Bile acids may also play a role in esophagitis, especially in patients with previous gastric surgery

  • 15% of patients have severe symptoms refractory to optimal medical treatment and will require surgery

Symptoms and Signs

• • Retrosternal and epigastric burning pain that occurs after eating and while sleeping or lying in a recumbent position and is relieved by drinking liquids, antacids, or by standing or sitting

  • Regurgitation of bitter or sour-tasting fluid

  • Pulmonary symptoms (wheezing, dyspnea) as the result of aspiration

  • Dysphagia, which results from inflammatory edema in the lower esophagus

Imaging Findings

• • Upper GI contrast radiography: Protrusion of the stomach upward through the esophageal hiatus

  • Esophagoscopy and biopsy: Determine the presence and degree of esophagitis and Barrett metaplasia

  • Manometry: Decreased mean resting pressure in the lower esophageal sphincter

  • Abnormal lower esophageal peristalsis: Low amplitude and decreased velocity of propagation of the peristaltic wave

  • pH monitoring: Increased exposure of the lower esophagus to acid, correlating with symptom onset

• • If sphincter function as measured manometrically seems intact, the possibility of delayed gastric emptying should be assessed by measuring the rate of passage from the stomach of a technetium Tc 99m-labeled solid meal

Rule Out

• • Cholelithiasis

  • Diverticulitis

  • Peptic ulcer disease

  • Achalasia

  • Coronary artery disease

• • Upper GI contrast radiography may indicate a sliding hiatal hernia and evidence of contrast reflux

  • Upper GI endoscopy with biopsy to assess presence and degree of esophagitis and evaluate for Barrett metaplasia

  • pH monitoring to document acid reflux and association with symptoms

  • Manometry to assess status of lower esophageal sphincter and force of peristalsis

When to Admit

• • Aspiration pneumonitis

• • Asymptomatic hiatal hernias require no treatment

  • Fundoplication: intra-abdominal placement of GEJ and buttress the gastroesophageal sphincter

Surgery

Indications

• • Persistent or recurrent symptoms despite good medical therapy

  • Complete mechanical incompetence of the sphincter (pressure < 6 mm Hg)

  • Presence or development of strictures