Gastro-oesophageal reflux disease and hiatus hernia

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Reflux occurs when gastric contents repeatedly enter the oesophagus and overcome clearance and mucosal defence. Transient lower-sphincter relaxations, an incompetent junction, impaired clearance, obesity and hiatus disruption contribute. Heartburn rising from the epigastrium and sour regurgitation are typical; cough, hoarseness and chest pain have many alternatives and need careful attribution. Dysphagia is not routine reflux until malignancy and stricture are assessed.

Sliding hernia mainly weakens the antireflux barrier. Paraoesophageal hernia places stomach beside the oesophagus and can cause postprandial pressure, early satiety, anaemia from Cameron lesions, dyspnoea, obstruction or volvulus. Endoscopy grades mucosal injury and biopsies suspicious tissue. Barium imaging or CT better displays large or rotating hernias. Manometry excludes major dysmotility before fundoplication, while pH or pH-impedance monitoring links symptoms to reflux when diagnosis remains uncertain.

Management combines weight reduction when appropriate, individual trigger modification, head-of-bed elevation for nocturnal symptoms, acid suppression and anatomical treatment. Omeprazole is taken before food and course length follows indication. Refractory symptoms require adherence and dose-timing checks before escalation. Surgery can restore anatomy and reinforce the junction, but dysphagia, gas-bloat, inability to belch, recurrence and operative injury must be discussed.

Key points

Typical GORD causes heartburn and acid regurgitation, but response to a PPI does not exclude cancer or prove reflux is the only diagnosis.
A sliding hiatus hernia moves the gastro-oesophageal junction above the diaphragm and promotes reflux; a paraoesophageal hernia can obstruct or volvulise without dominant heartburn.
For uncomplicated GORD use a full-dose PPI for four or eight weeks, then the lowest dose that controls symptoms. Severe oesophagitis needs eight weeks of the severe full dose and long-term full-dose maintenance rather than routine step-down.
Endoscopy assesses alarm symptoms, oesophagitis, Barrett mucosa, stricture and hernia anatomy but a normal result does not exclude reflux.
Ambulatory reflux monitoring and manometry answer persistent symptom and preoperative questions when anatomy and treatment response are insufficient.
Consider antireflux or hernia surgery only after objective assessment, shared decisions and confirmation that symptoms and anatomy plausibly match.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Junction incompetence

Transient sphincter relaxations, reduced basal sphincter pressure and hiatus disruption allow gastric contents to enter the oesophagus repeatedly.

Hiatus enlargement

Age, raised intra-abdominal pressure and connective-tissue laxity can widen the diaphragmatic hiatus, permitting sliding or paraoesophageal herniation.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Acid mucosal exposure
Reflux duration, impaired oesophageal clearance and reduced salivary neutralisation together determine whether typical symptoms, microscopic inflammation and visible erosive mucosal injury develop.
2
Sliding disruption
Separation of the lower sphincter from the diaphragmatic pinch weakens the antireflux barrier and enlarges the reflux reservoir.
3
Paraoesophageal compromise
Herniated stomach can compress, rotate and impair its own venous then arterial flow, producing obstruction, ischaemia and perforation.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Typical reflux syndrome

Retrosternal burning and acidic regurgitation after meals or on lying down support GORD when cardiac and alarm features are absent.

Mucosal alarmRed flag

Progressive dysphagia, bleeding, anaemia and weight loss are not reasons simply to double a PPI; they require endoscopic assessment.

Sliding hernia

Movement of the junction through the hiatus often accompanies reflux and may be incidental when small.

Paraoesophageal obstruction

Early satiety, postprandial chest pain, vomiting or iron deficiency can reflect a large hernia even without classic heartburn.

Volvulus pattern

Abrupt severe pain with unproductive retching and inability to swallow suggests rotation with threatened gastric perfusion.

Red flags requiring action

Dysphagia, weight loss, haematemesis, melaena, anaemia or persistent vomiting requires endoscopic or cancer-pathway assessment rather than repeated acid suppression.
Sudden pain and retching in a known large paraoesophageal hernia suggests volvulus or strangulation and needs emergency surgical review.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Upper-GI endoscopyFirst step
Why
Assess alarm symptoms, mucosal injury and visible hernia anatomy.
Interpretation and limitations
Oesophagitis supports reflux injury; normal mucosa does not exclude GORD. Biopsy suspected Barrett change, cancer or eosinophilic disease rather than treating appearance alone.
02
Ambulatory pH or pH-impedance monitoring
Why
Measure acid exposure and symptom association when diagnosis or surgery is uncertain.
Interpretation and limitations
Testing on or off acid suppression depends on the question. Association indices support correlation but do not make every reported symptom reflux-mediated.
03
High-resolution manometry
Why
Evaluate peristalsis and junction function before antireflux surgery or when dysphagia suggests motility disease.
Interpretation and limitations
Manometry is not a direct reflux test; its major value is excluding achalasia and guiding catheter placement and operative planning.
04
Barium contrast study
Why
Show hernia size, oesophageal emptying and intermittent obstruction dynamically.
Interpretation and limitations
Useful for large paraoesophageal anatomy and postoperative dysphagia, but it cannot grade microscopic inflammation or replace biopsy.
05
CT chest and abdomen
Why
Define volvulus, ischaemia, perforation and thoracic stomach in acute or complex hernia.
Interpretation and limitations
CT is urgent in suspected strangulation; a scan showing a hernia still requires correlation with symptoms and endoscopic findings.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Cardiac chest pain

Exertional pressure, autonomic symptoms and cardiovascular risk require ECG and acute coronary assessment rather than a therapeutic PPI trial.

Eosinophilic oesophagitis

Atopy, food impaction and fixed rings suggest eosinophilic inflammation, which requires multi-level biopsy despite reflux-like symptoms.

Reflux hypersensitivity and functional heartburn

Normal endoscopy alone establishes neither diagnosis. Reflux hypersensitivity has physiological acid exposure but a positive temporal association between symptoms and reflux events; functional heartburn has physiological exposure and absent reflux-symptom association after structural, inflammatory and major motor disorders have been appropriately excluded.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01AcuteTreat possible gastric volvulusFirst stepA patient with a large paraoesophageal hernia develops severe chest pain, repeated dry retching and shock.

1Begin ABCDE resuscitation, keep nil by mouth and call upper-GI surgery and anaesthesia immediately.
2Obtain urgent contrast CT if sufficiently stable to define rotation, perfusion and perforation.
3Decompress under expert endoscopic or operative control and proceed to urgent surgery when ischaemia or unresolved obstruction is present.
4Verify restoration of perfusion and monitor for leak, aspiration and recurrence after treatment.

02Persistent symptomsConfirm the mechanismHeartburn continues despite a prescribed PPI and surgery is being considered.

1Check adherence, pre-meal timing, dose, ongoing NSAIDs and whether symptoms are actually burning, regurgitation, dysphagia or functional pain.
2Perform endoscopy and appropriate reflux monitoring, with manometry before operative planning.
3Discuss continued medical care versus fundoplication or hernia repair using objective findings and patient priorities.
4Reassess symptom, swallowing and medication outcomes after the chosen strategy.

03MaintenanceMatch maintenance to mucosal severityEndoscopy after treatment shows healed reflux oesophagitis and no new alarm feature.

1Check the original grade and indication before changing treatment: uncomplicated GORD may step down to the lowest dose that controls symptoms, whereas severe oesophagitis remains on long-term full-dose PPI.
2For previous severe oesophagitis, continue the severe full dose used for healing, such as omeprazole 40 mg once daily, with adherence, tolerability and interaction review.
3Support weight and nocturnal positioning measures that match the person’s pattern, and give return advice for dysphagia, bleeding, weight loss or persistent vomiting.
4Record the maintenance indication and review response and adverse effects; do not convert severe disease to intermittent treatment simply because symptoms have settled.

Key medicines and prescribing safety1 treatment · regimens, roles and cautions

Suppresses gastric acid to heal reflux oesophagitis and reduce heartburn and acid regurgitation; it does not correct a paraoesophageal obstruction.

Omeprazole

For uncomplicated adult GORD, give omeprazole 20 mg orally once daily, preferably before food, for four weeks and continue to eight weeks if needed. For severe reflux oesophagitis, give 40 mg once daily for eight weeks and continue long-term full-dose 40 mg once daily after healing; reserve symptom-led reduction to the lowest controlling dose for uncomplicated disease.

Swallow the gastro-resistant tablet whole with water; do not chew or crush it. Nelfinavir is contraindicated and concomitant clopidogrel is discouraged. Investigate alarm symptoms before empirical treatment, review interacting medicines and long-term magnesium, vitamin B12, infection and fracture risks in context, and consider a lower dose in hepatic impairment rather than applying a universal maximum.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Peptic stricture

Repeated acid injury followed by healing can produce distal fibrotic narrowing, progressive solid-food dysphagia, nutritional restriction and acute food-bolus impaction.

Barrett metaplasia

Chronic reflux is associated with columnar replacement of distal squamous mucosa and an increased adenocarcinoma risk requiring risk-based surveillance.

Volvulus and strangulation

A paraoesophageal stomach can rotate, obstruct and lose perfusion, causing necrosis, perforation and mediastinal or peritoneal contamination.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Review symptom type, nocturnal disturbance, breakthrough timing and adherence after the initial treatment course.
Track dysphagia, weight, haemoglobin and iron status in a large paraoesophageal hernia.
After fundoplication or repair, assess swallowing, bloating, ability to belch, nutrition and recurrent reflux.
Reinvestigate new alarm symptoms even when the person has a longstanding reflux diagnosis.
Document why long-term PPI therapy continues and attempt appropriate dose reduction without stopping a clear protective indication.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Normal endoscopy is compatible with GORD

Reflux can be clinically and physiologically important without visible erosions, so objective monitoring may be needed before surgery.

Hernia type changes danger

Sliding hernia mainly affects reflux physiology; paraoesophageal hernia can obstruct, bleed or strangulate.

PPI failure needs diagnosis

Poor timing, non-acid reflux, hypersensitivity, motor disease and cardiac pain can all resemble resistant acid reflux.

Surgery trades symptoms

An effective fundoplication may reduce reflux yet create troublesome dysphagia or gas retention, making preoperative counselling essential.

11Common pitfallsFrequent interpretation and management errors.

01
Treating progressive dysphagia as ordinary reflux because heartburn is also present.
02
Calling every small sliding hernia the cause of non-specific upper abdominal symptoms.
03
Referring for antireflux surgery without manometry and objective confirmation when diagnosis is uncertain.
04
Missing volvulus because a paraoesophageal hernia was previously described as elective.

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