Define GORD & Hiatus Hernia. Describe its clinical features, complications and types.

The Concept — a Failed Valve

Gastro-oesophageal reflux disease (GORD) is the reflux of acidic gastric contents into the oesophagus in sufficient amount to cause symptoms or mucosal damage. It arises when the normal anti-reflux mechanism fails. That mechanism is not a single sphincter but a combination: the tone of the lower oesophageal sphincter (LOS), the acute angle of His where the oesophagus meets the stomach (a flap valve), the pinch of the diaphragmatic crura, and a short intra-abdominal segment of oesophagus. When these are disrupted — often by a hiatus hernia — reflux occurs.

Risk Factors

Anything that lowers LOS tone or raises intra-abdominal pressure promotes reflux: obesity, hiatus hernia, pregnancy, smoking, alcohol, fatty or large meals, and drugs that relax the LOS. Understanding these explains why lifestyle change is central to treatment.

Clinical Features

The classic symptom is heartburn — a retrosternal burning that is worse on lying down, bending or after meals — with acid regurgitation and waterbrash (excess salivation). Atypical presentations are important: chronic cough, hoarseness, nocturnal asthma and dental erosion can all be due to reflux. New dysphagia suggests a complication (stricture) and warrants endoscopy.

Complications

Chronic reflux damages the oesophagus in a recognisable sequence: oesophagitis → peptic stricture (causing dysphagia) → Barrett's oesophagus (columnar metaplasia, a premalignant change carrying a risk of adenocarcinoma), and bleeding with iron-deficiency anaemia. It is the risk of Barrett's and cancer that makes persistent reflux more than a nuisance.

Hiatus Hernia — the Types

A hiatus hernia is herniation of part of the stomach through the oesophageal hiatus of the diaphragm into the chest, and its two types behave very differently:

Investigation & Management

Investigation includes upper GI endoscopy (to grade oesophagitis, detect Barrett's and exclude cancer), 24-hour pH monitoring (the gold standard for confirming reflux), oesophageal manometry, and a barium swallow for the hernia. Management is stepwise:

• Lifestyle — weight loss, elevating the head of the bed, avoiding trigger foods and late meals, stopping smoking.
• Medical — proton pump inhibitors (PPIs) are the mainstay, with antacids and H2-blockers as adjuncts.
• Surgical — for refractory symptoms, volume reflux or complications: a Nissen fundoplication (wrapping the gastric fundus around the lower oesophagus to recreate a valve), with repair of the hiatus.

WHY the Anti-reflux Mechanism Fails

It is worth expanding on the physiology, because it explains both symptoms and surgery. Normally, transient reflux is prevented by the resting tone of the LOS and reinforced by the flap-valve effect of the acute angle of His and the 'pinchcock' action of the diaphragmatic crura during rises in intra-abdominal pressure. A sliding hiatus hernia pulls the junction into the chest, flattening the angle of His and separating the sphincter from the crural support — so the several layers of protection fail together, which is why hernia and reflux so often coexist and why surgery aims to restore this anatomy.

Surgery & its Complications

Nissen fundoplication (a 360° wrap of fundus around the lower oesophagus) recreates a competent valve and is highly effective, but the patient must be counselled about its characteristic side-effects: dysphagia (if the wrap is too tight), 'gas-bloat' syndrome and inability to belch or vomit, and flatulence. Careful patient selection — ideally those with proven acid reflux on pH testing who responded to PPIs — gives the best results, and a partial (e.g. Toupet) wrap may be chosen where oesophageal motility is poor.

A Note on Atypical & Extra-oesophageal Reflux

Reflux does not always present as heartburn. 'Silent' or extra-oesophageal reflux can present to other specialties — as chronic cough, recurrent laryngitis and hoarseness, throat clearing, or worsening asthma — because refluxed acid irritates the larynx and airway. Recognising this prevents prolonged mistreatment of a 'respiratory' or 'ENT' complaint that is actually GORD, and a trial of PPI or pH testing confirms the link.

• PPIs are the mainstay of GORD; 24-hour pH monitoring is the gold-standard diagnostic test.
• Surgery = Nissen fundoplication for refractory reflux/complications.
• Rolling (para-oesophageal) hernia → surgical repair (strangulation risk).

Barrett oesophagus is the premalignant endpoint of chronic reflux.

• GORD = reflux causing symptoms/damage from failure of the anti-reflux mechanism (LOS tone, angle of His, crura, intra-abdominal oesophagus).
• Heartburn worse lying/bending/after meals + regurgitation; atypical: cough, hoarseness, asthma; new dysphagia = complication.
• Complications: oesophagitis → stricture → Barrett's (→ adenocarcinoma) → bleeding.
• Hiatus hernia: sliding (90%, reflux) vs rolling/para-oesophageal (strangulation/volvulus risk).
• Lifestyle + PPIs (mainstay); Nissen fundoplication for refractory disease; repair a rolling hernia surgically.