There is that pain again… burning, pressure in the chest, throat, or back. Have you ever wondered why you experience persistent heartburn?
Eating and digestion are actually very complex processes that rely on many coordinated bodily functions. The stomach produces hydrochloric acid to aid in the digestion of food. The process begins in the mouth, where chewing stimulates the salivary glands to increase saliva production, helping soften food and begin the breakdown. At the same time, neural and hormonal signals trigger the stomach to increase acid production in preparation for digestion.
When this system works properly, food is broken down efficiently and moves through the digestive tract as intended. However, when gastric acid refluxes into the esophagus, it can lead to a range of symptoms collectively known as gastroesophageal reflux disease (GERD). The most common symptom is a burning sensation in the upper abdomen or chest that may radiate upward. Less typical symptoms include chronic cough, nocturnal asthma, and dental enamel erosion. In severe or prolonged cases, repeated acid exposure can lead to changes in the distal esophageal mucosa known as Barrett’s esophagus, which carries a risk of progression to esophageal cancer if left untreated.
What Causes GERD?
GERD is most often caused by transient relaxation or dysfunction of the lower esophageal sphincter (LES), which allows stomach contents to reflux into the esophagus. Many patients notice symptoms worsen when lying flat, which is why elevating the head of the bed or sleeping in a reclined position can help by using gravity to reduce reflux.
Several risk factors can contribute to LES relaxation, including smoking, alcohol, caffeine, fatty foods, chocolate, and hiatal hernias. In some cases, lifestyle changes such as avoiding trigger foods, especially before bedtime, can significantly reduce symptoms. However, when a hiatal hernia is present, management becomes more complex.
A hiatal hernia occurs when a defect in the diaphragm allows part of the stomach to protrude into the chest cavity. This disrupts normal LES anatomy and makes effective closure more difficult. Hiatal hernias are generally classified into two main types: a sliding hernia, the most common, where the gastroesophageal junction moves into the chest, and a paraesophageal hernia, where part of the stomach herniates alongside the esophagus, with or without displacement of the gastroesophageal junction.
Treatment Options
Treatment for GERD typically begins with medical management. Common therapies include H2 receptor blockers and proton pump inhibitors (PPIs), both of which reduce gastric acid production through different mechanisms. By decreasing acid exposure, these medications allow the inflamed esophageal tissue to heal.
In cases where symptoms persist despite medical therapy, particularly when a hiatal hernia is contributing to significant LES dysfunction, surgical intervention may be considered. Preoperative evaluation often includes esophagogastroduodenoscopy (EGD) to directly visualize the upper gastrointestinal tract, as well as pH monitoring to measure acid reflux. These studies help determine the likelihood of symptom improvement with surgery.
EGD is a short, simple procedure that involves inserting a camera down the throat into the stomach and the first portion of the small bowel. Air is used to insufflate the esophagus, stomach, and bowel to allow full visualization of the anatomy.
If you are experiencing symptoms of heartburn or reflux, it is important to discuss them with your primary care provider or a surgeon to explore appropriate evaluation and treatment options.
