GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD)
& LAPAROSCOPIC NISSEN FUNDOPLICATION
REFLUX DISEASE (G.E.R.D.)
(Hiatal Hernia and Heartburn)
Published by The National Institute of Health
GARTH H. BALLANTYNE, M.D., M.B.A.
SURGEON IN CHIEF
BOARD CERTIFIED IN:
GENERAL SURGERY & COLON AND RECTAL SURGERY
SURGEON IN CHIEF
LAWRENCE & MEMORIAL HOSPITAL
NEW LONDON, CT 06320
PRACTICE LIMITED TO LAPAROSCOPIC SURGERY
CONTACT US AT:
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MORE INFORMATION ABOUT ADVANCED
MORE INFORMATION ABOUT GERD
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 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. Figure I shows the location of the
LES between the esophagus and the stomach.
The severity of GERD depends on LES dysfunction as well as the type 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 a hiatal hernia may weaken the LES and cause reflux. Hiatal hernia
occurs when the upper part of the stomach moves up into the chest through a small
opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating
the stomach from the chest. (See Figure 2.) 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 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, treatment may be necessary if
the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood
supply, i.e., paraesophageal hernia) or is complicated by severe GERD or esophagitis
(inflammation of the esophagus). The doctor may perform surgery to reduce the size of
the hernia or to prevent strangulation.
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, 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.
What Does Heartburn 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
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.
Avoiding foods and beverages that can weaken the LES is recommended. These foods
include chocolate, peppermint, fatt7y foods, coffee, and alcoholic beverages. Foods and
beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices,
tomato products, and pepper, should also be avoided.
Decreasing the size of portions at mealtime may also help control symptoms. Eating
meals at least 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.
Cigarette smoking weakens the LES. Therefore, stopping smoking is important to reduce
Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge
reduces heartburn by allowing gravity to minimize reflux of stomach contents into the
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. An antacid combined with a foaming agent such as alginic acid helps some people.
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
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, famotidine, nizatidine, and
ranitidine. Another type of drug, the proton pump (or acid pump) inhibitor omeprazole
inhibits an enzyme (a protein in the acid-producing cells of the stomach) necessary for
acid secretion. The acid pump inhibitor lansoprazole is currently under investigation as a
new treatment for GERD.
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 cisapride, bethanechol, and metoclopramide.
Tips To Control Heartburn
1. Avoid foods and beverages that affect LES pressure or irritate the esophagus lining,
including fried and fatty foods, peppermint, chocolate, alcohol, coffee, citrus fruit and
juices, and tomato products.
2. Lose weight if overweight. -
3. Stop smoking.
4. Elevate the head of the bed 6 inches.
5. Avoid lying down 2 to 3 hours after eating.
6. Take an antacid.
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 tissue 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.
The Bernstein test (dripping a mild acid through a tube placed in the mid-esophagus) is
often performed as part of a complete evaluation. This test attempts to confirm that the
symptoms result from acid in the esophagus. 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.
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 Barrett's esophagus, which is severe
damage to the skin-like lining of the esophagus. Doctors believe this condition may be a
precursor to esophageal cancer.
Although GERD can limit daily activities and productivity, it is rarely life threatening.
With an understanding of the causes and proper treatment most people will find relief.
Cramer T. A burning question: When do you need an antacid? FDA Consumer 1992; 26(l):
19-22. This article for consumers provides general information about antacids.
Larson DE, Editor-in-chief Mayo Clinic Family Health Book. New York: William Morrow and
Company, Inc., 1990. This general medical guide includes sections about esophageal reflux and
Richter JE. Why does surgery work for GERD? Practical Gastroenterology 1993; XVII(10):
10-18. This article for physicians describes antireflux surgery.
Sutherland JE. Gastroesophageal reflux disease: when antacids aren't enough. Postgraduate
Medicine 1991; 89(7): 45-53. This article for primary care physicians provides guidelines to
determine if a patient has reflux disease and offers treatment methods.
National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892-3570
The National Digestive Diseases Information Clearinghouse is a service of the National Institute of
Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health, under the
U.S. Public Health Service. The clearinghouse, authorized by Congress in 1980, provides
information about digestive diseases and health to people with digestive diseases and their families,
health care professionals, and the public. The clearinghouse answers inquiries; develops, reviews,
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 reviewed carefully for scientific accuracy, content,
and readability. Publications produced by outside sources are also reviewed carefully before being
used to supplement clearinghouse materials when responding to inquiries.
This publication is not copyrighted. The clearinghouse encourages users of this fact sheet to
duplicate and distribute as many copies as desired.
NIH Publication No. 94-882 September 1994
or browse these other pages:
- GARTH H. BALLANTYNE, M.D. - BACKGROUND AND TRAINING Dr.
Ballantyne's background, training, academic career and clinical experience are outlined. In
addition a full list of his PUBLICATIONS and LECTURES are included on linked web
pages. Finally, the INSURANCE PLANS in which Dr. Ballantyne participates are indicated
on another linked page.
- LAPAROSCOPIC SURGERY - A new type of surgery that decreases the size of incisions
used by surgeons that causes less pain and speeds recovery compared to traditional surgical
techniques. It is also called Keyhole Surgery, Band Aid Surgery and Minimally Invasive
- LAPAROSCOPIC COLECTOMY - Laparoscopic removal of a part of the colon for
diverticulitis, colon cancer, rectal cancer, colorectal cancer, Crohn's Disease, Chronic
Ulcerative Colitis, rectal prolapse, volvulus, sigmoid volvulus, cecal volvulus or constipation.
- LAPAROSCOPIC CHOLECYSTECTOMY - Surgical removal of the gallbladder for
gallstones, cholelithiasis, acute cholecystitis, chronic cholecystitis, choledocholithiasis, biliary
colic or common bile duct stones.
- LAPAROSCOPIC INGUINAL HERNIA REPAIR - Surgical repair of inguinal hernia,
femoral hernia, double hernia, recurrent hernia, groin hernia, indirect hernia or direct hernia.
- THERAPY OF GASTRO-ESOPHAGEAL REFLUX DISEASE - Treatment of hiatal
hernia, heartburn, acid reflux, reflux esophagitis, Barrett's esophagus or esophageal stricture.
- SURGICAL TREATMENT OF GASTRO-ESOPHAGEAL REFLUX DISEASE -
Selection of patients and selection of a surgeon for Laparoscopic Nissen Fundoplication.
- LAPAROSCOPIC NISSEN FUNDOPLICATION - Surgical repair of a hiatal hernia,
acid reflux or heartburn.
- WHICH IS ALTERNATIVE MEDICINE? TRADITIONAL WESTERN MEDICINE,
MODERN EXPERIMETAL MEDICINE or LAPAROSCOPIC SURGERY.
Copyright 1996, Garth Hadden Ballantyne, M.D., P.C. All rights reserved.
50 East 69th Street, New York, New York 10021 (212)-249-2626 or (800)-LAP-SURG