Gastroesophageal reflux disease (GERD) occurs when an incompetent lower esophageal sphincter allows gastric acid to reflux into the esophagus, causing mucosal irritation. The classic symptom of GERD is a substernal burning pain that occurs after meals and is exacerbated by lying supine. Acid reflux can also cause respiratory symptoms such as coughing, laryngitis, and asthma-like wheezing secondary to aspiration. Because the symptoms of GERD are often nonspecific, the diagnosis may require a complement of tests including upper endoscopy, a barium swallow, esophageal manometry, and a 24-h pH test.

Over time, the persistent irritation caused by severe reflux can lead to the development of Barrett’s esophagus, in which the normal squamous epithelium of the distal esophageal mucosa morphs into a glandular columnar epithelium. This process, known as intestinal metaplasia, can progress further into high-grade dysplasia and ultimately adenocarcinoma of the esophagus. Therefore the treatment of GERD serves to both relieve patient symptoms, and to lower the risk of future malignancy.

The treatment of GERD begins with lifestyle modifications such as advising patients to avoid foods that induce reflux, avoid eating before bedtime, elevate the head of the bed, quit smoking, and lose excess body weight. Medications to treat GERD include H₂-blockers and proton-pump inhibitors. Surgical therapy for GERD is indicated when there is a failure of medical therapy to alleviate the symptoms, and/or the esophageal injury progresses to Barrett’s esophagus. It is important to realize that in patients who are found to have high-grade dysplasia, invasive carcinoma is often also frequently present. Therefore an esophageal resection should be considered in patients with diffuse high-grade dysplasia.

GERD is sometimes associated with the presence of a hiatal hernia. A hiatal hernia occurs when the esophageal hiatus of the diaphragm is lax, and allows herniation of abdominal contents into the mediastinum. GERD and hiatal hernias are two separate diagnoses, which frequently coexist, although either can occur without the other. A Type I hernia, known as a sliding hiatal hernia, involves migration of only the GE junction into the chest. This change in location of the lower esophageal sphincter from the high pressure of the abdomen to the low pressure of the thorax can allow acid reflux to occur. Type I hernias are by far the most common kind of hiatal hernias, and are often discovered incidentally. As in other patients with GERD, treatment of individuals with Type I hiatal hernias is with medical therapy first, and surgical fundoplication as needed.

In a Type II—or paraesophageal—hernia, the GE junction remains in the abdomen, but the fundus of the stomach herniates up into the thorax. A Type III hernia is a combination of Types I and II, where both the GE junction and the fundus are in the chest (Fig. 4.1). Finally, in Type IV hernias, herniation of the stomach is accompanied by other organs such as the colon or the spleen (Fig. 4.2). Hernia Types II–IV are distinct from Type I hernias in that the herniated portion of bowel is at risk for becoming acutely incarcerated and strangulated. Therefore, all patients who are discovered to have a Type II–IV hernia should undergo surgical repair upon diagnosis, even if asymptomatic.