Gastro-oesophageal reflux disease (GORD) and hiatus hernia
Reflux is the backward flow of stomach contents into the oesophagus. Almost everyone experiences it occasionally; it becomes a disease when it is frequent enough to cause troublesome symptoms or damage to the oesophageal lining. Most patients are managed well with medication. A minority are better served by an operation, and identifying which is the useful clinical work.
How it forms
The junction between oesophagus and stomach is not a simple valve but a barrier assembled from several components working together:
- the lower oesophageal sphincter, a thickened ring of circular muscle
- the crura of the diaphragm, which pinch the oesophagus as it passes through the hiatus — an external sphincter
- the angle of His, the acute angle at which the oesophagus enters the stomach, creating a flap-valve effect
- the intra-abdominal length of oesophagus, compressed by abdominal pressure
- the phreno-oesophageal ligament, anchoring the junction below the diaphragm
Reflux occurs when this assembly fails. The commonest mechanism is transient relaxation of the sphincter unrelated to swallowing. Others include a weak resting sphincter, raised intra-abdominal pressure from obesity or pregnancy, delayed gastric emptying, and impaired oesophageal clearance.
A hiatus hernia is the structural version of the same failure. The phreno-oesophageal ligament stretches with age and repeated pressure, the gastro-oesophageal junction slides upward through the hiatus into the chest, and the diaphragmatic component of the barrier is lost along with the angle of His and the intra-abdominal oesophageal segment. This is a sliding (type I) hiatus hernia, much the commonest type, and it explains why hernia and reflux so often coexist.
Damage follows from contact time. Acid, pepsin and bile refluxing repeatedly into an oesophagus not built to withstand them cause inflammation (oesophagitis), and over years may produce stricture, or the metaplastic change of Barrett's oesophagus.
Symptoms
- Heartburn — retrosternal burning, worse lying flat, bending forward, or after large or fatty meals
- Regurgitation of acid or food into the throat
- waterbrash, belching, bloating
- chest pain, which can mimic cardiac pain and must be distinguished from it
- dysphagia — suggesting stricture, and always requiring investigation
Extra-oesophageal symptoms are commonly attributed to reflux and often are not caused by it: chronic cough, hoarseness, sore throat, asthma, dental erosion. These respond less predictably to both medication and surgery, and patients should be told so plainly before an operation is contemplated.
Alarm features requiring prompt endoscopy: difficulty swallowing, painful swallowing, weight loss, anaemia, vomiting, gastrointestinal bleeding, or new symptoms in an older patient.
How the diagnosis is made
Typical symptoms in a younger patient without alarm features may reasonably be treated empirically with acid suppression. Investigation is needed where symptoms persist, where alarm features are present, or where surgery is being considered — and before surgery it is mandatory, not optional.
- Endoscopy — assesses oesophagitis, hernia size, stricture, Barrett's change, and excludes malignancy. A normal endoscopy does not exclude reflux.
- Ambulatory pH or pH-impedance monitoring — the objective test. It confirms pathological acid exposure and, crucially, correlates symptoms with reflux events. Impedance also detects non-acid and gas reflux.
- High-resolution manometry — measures oesophageal motility. Essential before antireflux surgery, because performing a full wrap on a patient with achalasia or severely impaired peristalsis produces disabling dysphagia.
- Barium swallow — useful for defining anatomy, particularly large or complex hernias.
- Gastric emptying study where delayed emptying is suspected.
Treatment
Lifestyle and medical
Weight loss is the single most effective non-drug measure and is consistently under-emphasised. Raising the head of the bed, avoiding late meals, reducing alcohol, and stopping smoking all help. Proton pump inhibitors are highly effective for acid-related symptoms and heal oesophagitis in most patients; alginates and H2 blockers have supporting roles.
Medication controls acid but does not restore the barrier, which is why regurgitation and volume reflux often persist despite adequate acid suppression.
Surgery
Antireflux surgery aims to reconstruct the barrier: reduce the hernia, excise the sac, close the diaphragmatic hiatus, restore intra-abdominal oesophageal length, and construct a fundoplication — wrapping the gastric fundus around the lower oesophagus.
The principal variants are the Nissen (360°) and the Toupet (270° posterior partial) fundoplication. Partial wraps produce less dysphagia and gas-bloat with broadly comparable reflux control, and are generally preferred where motility is impaired.
Surgery is considered for patients with objectively confirmed reflux who have inadequate symptom control on medication, who have volume regurgitation, who cannot tolerate or do not wish to take lifelong medication, or who have a large hernia with mechanical symptoms.
The critical point about patient selection: the best results follow in patients with typical symptoms, objectively proven reflux, and a good response to acid suppression. Operating on patients with atypical symptoms and normal pH studies produces disappointment, and the pre-operative work-up exists precisely to avoid it.
In patients with obesity and reflux, gastric bypass addresses both problems and is often the better operation.
Recovery
Laparoscopic fundoplication typically involves one to two nights in hospital. A modified diet — soft then gradually normal — is followed for two to six weeks while post-operative swelling settles. Early dysphagia is expected and usually resolves. Return to normal activity is within two to four weeks.
Recognised longer-term effects include inability to belch or vomit, gas-bloat, and increased flatulence. Some patients eventually resume acid-suppressing medication. These should be discussed before surgery rather than discovered after.
Common questions
Is a hiatus hernia dangerous?
A small sliding hiatus hernia is very common and in itself harmless — it matters only because it contributes to reflux. Large hernias, where a substantial part of the stomach sits in the chest, are a different matter and are assessed separately.
Do I need an operation for reflux?
Most people do not. Medication controls symptoms well for the majority. Surgery is worth considering if medication does not control your symptoms, if you regurgitate food or fluid rather than simply feeling burning, if you have a large hernia, or if you do not want to take tablets for the rest of your life.
Is it safe to take acid tablets long term?
For most people, yes. Long-term use has been associated with certain risks in observational studies, but these are small and the evidence for direct cause is limited. The practical approach is to use the lowest dose that controls symptoms and to review the need periodically.
Will surgery stop my cough or hoarseness?
Possibly, but far less predictably than it relieves heartburn and regurgitation. Cough, hoarseness and throat symptoms often have other causes even when reflux is present. This should be tested and discussed carefully before deciding on an operation.
What is the recovery like after reflux surgery?
Usually one or two nights in hospital and two to four weeks before returning to normal activity. You will be on a soft diet for several weeks. Difficulty swallowing in the early weeks is expected and settles as the swelling resolves.
Will I be able to burp or vomit afterwards?
After a full (360°) wrap, belching can be difficult and vomiting may be impossible, which is why some patients experience bloating. A partial wrap reduces this. Which is appropriate for you depends on your oesophageal muscle function, which is measured before surgery.
Can reflux turn into cancer?
Long-standing reflux can lead to Barrett's oesophagus, a change in the lining that carries a small increased risk of oesophageal cancer. The great majority of people with reflux never develop it. Persistent symptoms, particularly over many years, are a reason to have an endoscopy rather than a reason to be alarmed.
Related conditions
Other conditions of the oesophagus covered on this site:
- Paraoesophageal hernia
- Achalasia
- Barrett's oesophagus
- Oesophageal diverticulum (Zenker's and epiphrenic)
- Benign tumours of the oesophagus
- Oesophageal cancer
- Oesophageal perforation and Boerhaave syndrome
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history, examination and investigations.