The hiatus is an opening in the diaphragm — the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus (food pipe) goes through the hiatus and attaches to the stomach. In a hiatal hernia (also called hiatus hernia) the stomach bulges up into the chest through that opening.
There are two main types of hiatal hernias: sliding and paraesophageal (next to the esophagus). In a sliding hiatal hernia, the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus. This is the more common type of hernia.
The paraesophageal hernia is less common, but is more cause for concern. The esophagus and stomach stay in their normal locations, but part of the stomach squeezes through the hiatus, landing it next to the esophagus.
GERD is usually caused by changes in the barrier between the stomach and the esophagus, including abnormal relaxation of the lower esophageal sphincter, which normally holds the top of the stomach closed, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia. These changes may be permanent or temporary.
Hiatal hernia, which increases the likelihood of GERD due to mechanical and motility factors.
Obesity: increasing body mass index is associated with more severe GERD. In a large series of 2000 patients with symptomatic reflux disease, it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index.
Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production.
Hypercalcemia, which can increase gastrin production, leading to increased acidity. Scleroderma and systemic sclerosis, which can feature esophageal dysmotility. The use of medicines such as prednisolone.
Visceroptosis or Glénard syndrome, in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach.
Obstructive sleep apnea Gallstones, which can impede the flow of bile into the Duodenum, which can affect the ability to neutralize gastric acid.
The most-common symptoms of GERD are:
Difficulty in swallowing (dysphagia)
Pain with swallowing/sore throat (odynophagia)
Increased salivation (also known as water brash)
Where hiatal 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.