Reflux and hiatal hernia: when medication is not enough

Burning behind the breastbone after meals is among the commonest digestive symptoms. In most cases gastro-oesophageal reflux is controlled with lifestyle measures and medication. In a subgroup of patients, however, the cause is mechanical — a hiatal hernia — and medication then treats the symptom without correcting the problem.

Reflux and hiatal hernia: how they are linked

Where the oesophagus meets the stomach there is a valve mechanism that prevents gastric contents from rising. It is formed by the lower oesophageal sphincter together with the diaphragm, which surrounds it like a ring.

In a hiatal hernia the diaphragmatic opening widens and part of the stomach moves up into the chest. The valve loses its support, and reflux becomes easier and more frequent.

The two are not the same: reflux occurs without a hernia, and small hiatal hernias often cause no symptoms at all. Their relationship, however, explains why some patients do not respond to medication.

Symptoms — typical and atypical

• Typical: heartburn behind the sternum, regurgitation of acid or food, discomfort that worsens when lying down, after a large meal or on bending forward.
• Atypical: chronic dry cough, hoarseness especially in the morning, a sensation of a lump in the throat, sore throat, poorly controlled asthma, even dental enamel erosion.
• With large hernias: early fullness after a few mouthfuls, breathlessness after eating, palpitations, chest pain.

Chest pain from reflux can mimic cardiac pain. Any new or severe chest pain should be assessed by a cardiologist first.

The diagnostic work-up

For mild symptoms a trial of treatment is often started without investigation. Once surgery is being considered, however, the assessment must be complete:

• Gastroscopy: demonstrates oesophagitis, stricture and the size of the hernia, and excludes other disease. Biopsies are taken where indicated.
• 24-hour pH monitoring (with or without impedance): objectively documents pathological reflux and whether symptoms correlate with reflux episodes.
• Oesophageal manometry: assesses motility. It is essential before surgery, because a significant motility disorder changes the type of fundoplication chosen.
• Barium swallow or CT: mainly useful in large or para-oesophageal hernias, to map the anatomy.

pH monitoring and manometry are not procedural formalities: surgery without objective documentation of reflux gives substantially worse outcomes.

When medication is enough

First-line treatment is a proton pump inhibitor alongside practical measures: smaller and more frequent meals, avoiding food 2–3 hours before bed, raising the head of the bed, stopping smoking and losing weight.

For the great majority of patients this is sufficient. Medication controls acidity effectively and heals oesophagitis.

When surgery is indicated

Surgery is not an alternative simply because someone is tired of taking tablets. The recognised indications are:

• Inadequate symptom control despite correct and sufficient medical therapy.
• Persistent regurgitation — where the problem is mechanical, medication reduces acidity but not the reflux itself.
• Complications: peptic stricture, ulceration, severe oesophagitis, or respiratory manifestations attributed to reflux.
• Large or para-oesophageal hernia with symptoms, particularly where there is a risk of gastric volvulus.
• Patient preference against lifelong medication, provided reflux is objectively documented.

What the operation involves

It is performed laparoscopically or robotically through small ports and has two components: returning the stomach to the abdomen with closure of the diaphragmatic opening, and constructing a new valve — fundoplication — by wrapping the fundus of the stomach around the oesophagus.

The wrap may be complete (Nissen, 360°) or partial (Toupet, 270°). The choice depends largely on manometry findings. Large defects may require mesh reinforcement.

Hospital stay is usually 1–2 days. A staged diet is followed over the first weeks, from liquid to soft and then normal. Mild difficulty swallowing in the early weeks is expected and usually settles.

More detail on the pages for gastro-oesophageal reflux disease and hiatal hernia.