One of the surprising causes of gastroesophageal reflux disease (GERD) and other upper-GI disorders involves having parts of your internal anatomy out of place-a condition called hiatal hernia. The esophagus passes through a small opening in the diaphragm, which separates the chest cavity from the abdominal cavity. The lower esophageal sphincter at the bottom of the esophagus normally is aligned with this opening in the diaphragm (the hiatus). The rest of the esophagus is located above the diaphragm in the chest cavity, and the stomach is located below the diaphragm in the abdominal cavity.
The incidence of a hiatal hernia increases with age, from 10 percent in people younger than 40 to 70 percent of people older than 70. If you are in this older group, your lower esophageal sphincter and a small portion of your stomach may have slipped through the opening in the diaphragm and are now protruding into your chest cavity. The resulting separation between the lower esophageal sphincter and the diaphragm may weaken the barrier against reflux of acid from the stomach into the esophagus, increasing the risk of GERD and erosive esophagitis.
Most hiatal hernias produce no symptoms and are found by chance during tests or other health problems. However, when the lower esophageal sphincter is significantly displaced from its normal position in the hiatus, reflux symptoms (such as heartburn) can occur.
Hiatal hernias are diagnosed by an upper GI series of X-rays or an upper endoscopy. If a hiatal hernia is not causing symptoms, treatment isn’t needed. When symptoms such as recurrent heartburn arise, they can often be relieved with lifestyle measures or medication. Very large hiatal hernias may need to be surgically repaired, as they can cause swallowing problems and create pressure that affects the functioning of surrounding organs. If a hiatal hernia is causing severe reflux that is not responding to medical therapy, it also may be repaired surgically-by pulling the stomach back into the abdominal cavity and repairing the defect in the diaphragm that allowed the stomach to slip into the chest cavity.