From the Guidelines
A paraesophageal hernia predisposes individuals to gastroesophageal reflux disease (GERD) for four main reasons, primarily due to the disruption of normal gastroesophageal junction anatomy, creation of an acid reservoir, delayed gastric emptying, and increased transient lower esophageal sphincter relaxations, as supported by recent clinical practice updates 1.
Reasons for Predisposition to GERD
- The abnormal positioning of the stomach as it herniates into the chest compromises the lower esophageal sphincter (LES) function, which normally prevents acid reflux, as discussed in the context of personalized approaches to GERD management 1.
- Mechanical alterations from the hernia create a reservoir for acid in the herniated portion of the stomach, allowing acid to easily reflux into the esophagus when patients change positions, highlighting the importance of patient education on GERD mechanisms and lifestyle modifications 1.
- Paraesophageal hernias frequently delay gastric emptying, increasing the time acid remains in the stomach and raising the likelihood of reflux episodes, which can be addressed through dietary changes and stress-reducing activities 1.
- The hernia can cause increased transient LES relaxations, which are inappropriate relaxations of the sphincter not associated with swallowing, allowing acid to flow upward, and may require adjunctive strategies beyond acid suppression 1.
Management Considerations
Management of GERD in patients with paraesophageal hernias typically involves proton pump inhibitors for symptom control, along with lifestyle modifications such as avoiding meals within 3 hours of bedtime and elevating the head of the bed, as recommended in recent clinical practice updates 1.
- Proton pump inhibitors like omeprazole (20-40mg daily) or pantoprazole (40mg daily) are commonly used for symptom control.
- Lifestyle modifications include avoiding trigger foods, elevating the head of the bed 6-8 inches, and avoiding meals within 3 hours of bedtime.
- Surgical repair may be necessary for large hernias or when symptoms persist despite medical therapy, with laparoscopic approaches being the preferred method for most patients, emphasizing the need for a personalized approach to management 1.
From the Research
Paraesophageal Hernia and GERD
The relationship between paraesophageal hernia and gastroesophageal reflux disease (GERD) is complex, with several factors contributing to the predisposition of GERD in patients with paraesophageal hernia. Some of the key reasons include:
- Age: Patients with paraesophageal hernia are typically older, with a mean age of 60.4 years, compared to GERD patients who have a mean age of 49.1 years 2.
- Co-morbidities: Paraesophageal hernia patients often have more co-morbidities than GERD patients, which can contribute to worse outcomes and increased risk of GERD 2.
- Anatomical abnormalities: Paraesophageal hernia involves significant distortion of the anatomy and function of the esophagus, stomach, gastroesophageal junction, mediastinum, lungs, and heart, which can lead to GERD symptoms 3.
- Lower esophageal sphincter (LES) dysfunction: LES dysfunction is a primary cause of GERD, and paraesophageal hernia patients may be more likely to experience LES dysfunction due to the anatomical abnormalities associated with the condition 4.
Risk Factors for GERD
In addition to the factors mentioned above, other risk factors for GERD include:
- Obesity: Obesity is a significant risk factor for GERD, and weight loss is often recommended as a lifestyle modification to manage GERD symptoms 4.
- Smoking: Smoking is also a risk factor for GERD, and cessation of tobacco use is recommended to manage GERD symptoms 4.
- Sedentary lifestyle: A sedentary lifestyle can contribute to GERD symptoms, and increasing physical activity is often recommended as a lifestyle modification to manage GERD 4.
Management of GERD
The management of GERD typically involves a combination of lifestyle modifications, pharmacologic therapy, and procedural interventions. Some of the key management options include:
- Proton pump inhibitors (PPIs): PPIs are the mainstay of pharmacological therapy for GERD, and are often prescribed as a first-line treatment 5, 4.
- Lifestyle modifications: Lifestyle modifications such as weight loss, avoiding lying down after meals, and ceasing tobacco use are often recommended to manage GERD symptoms 4.
- Procedural interventions: Procedural interventions such as fundoplication and magnetic sphincter augmentation may be considered for patients who do not respond to pharmacologic therapy or who wish to discontinue medication 4, 6.