The esophagus, which is a muscular tube that extends from the mouth to the stomach, normally enters the stomach through a small hole in the diaphragm. The diaphragm is a muscle that separates the stomach from the chest and helps to keep the stomach in place. It also helps to prevent the reflux of food and acid from the stomach back up into the esophagus. Obesity, coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen, which allows the upper portion of the stomach to slide up into the chest cavity through the hole in the diaphragm. The portion of the stomach that is now located above the diaphragm is known as a hiatal hernia. Food and acid can accumulate in this hernia “sac” and easily reflux into the esophagus causing heartburn and irritation of the esophagus.
Many otherwise healthy people have small hiatal hernias and have symptoms. People who do have reflux symptoms can control these with diet and lifestyle changes including weight loss, small meals, and abstinence from tobacco, alcohol, caffeine, and peppermint. Symptoms can also be relieved with different medications that cut down on the acid that is produced in the stomach. People with persistent reflux symptoms or a large hiatal hernia in danger of becoming strangulated (twisted in a way that cuts off the blood supply) usually require surgery. This surgery is known as a “fundoplication” can often be performed laparoscopically and involves wrapping part of the stomach around the end of the esophagus to prevent movement into the chest. After surgery, people may either have no reflux symptoms or are able to manage their symptoms with low dose medications.