The stomach produces acid which helps digest food. The lining of the stomach has a special protective coating which prevents damage from the acid. Other parts of the intestine do not have this coating and can be damaged by acid. Normally, the stomach contents are kept in the stomach by a combination of muscles and arrangements which prevents them from being pushed back up into the esophagus by the pressure inside the stomach. There are muscles in the wall of the esophagus and stomach, which combine with the effect of the normal shape of the junction between the esophagus and stomach to produce an area of high pressure which functions as a "valve". If this arrangement is disturbed, acid and food from the stomach can "reflux" (flow back) into the esophagus, and cause heartburn, or irritation of the lining of the esophagus.

One of the most common causes of reflux is a hiatus hernia. This simply means that the opening in the diaphragm through which the esophagus passes into the abdomen is larger than usual, and that the stomach can slide up through it into the chest. When this happens, the low pressure inside the chest deactivates the valve mechanism, and allows reflux. Reflux can also occur if the muscles of the esophagus and stomach do not work normally.

In most cases, reflux is not a major problem and can be controlled by a few simple measures:

1. Avoid foods which are not quickly digested and which sit in the stomach for long periods, primarily dairy products and other fatty foods. Since most reflux occurs at night, do not eat for three hours before bedtime.
2. Avoid foods which increase acid secretion, such as caffeine, chocolate, alcohol.
3. No smoking.
4. If overweight, weight loss can reduce the excess pressure in the abdomen.
5. Since most reflux occurs at night, elevate the head of the bed on six-inch blocks. Just using pillows doesn't work.

These five measures, if followed, will control symptoms in most people with moderate symptoms of reflux. If symptoms are severe, several different types of medication may help:

1. Antacids: these neutralize acid, and if used after meals, can prevent symptoms of reflux.
2. H2 Blockers: these medications, such as Tagamet, Zantac, and Pepcid, all reduce acid secretion by the stomach, and generally work better than antacids.
3. Proton pump inhibitor: Prilosec (omeprazole) is the best acid-inhibitor, and works even better than H2 blockers. It's more expensive, and may cause some problems if used for long periods.
4. Motility enhancers: these drugs, such as Reglan and Propulsid, speed up emptying of the stomach, and may reduce reflux. They don't work very well.

In the few patients whose symptoms are very severe, and not controlled by the measures outlined above, "anti-reflux" surgery may provide the best solution. This type of operation is directed at recreating the valve mechanism at the junction between the esophagus and the stomach. There is some experience with performing these operations laparoscopically, but we do not yet recommend this approach for several reasons:

First, there is no improvement in length of hospital stay with the laparoscopic procedure. Second, there is no long-term experience with the results of the procedure performed laparoscopically. Third, the procedure is performed relatively infrequently. Laparoscopic procedures require more experience than open operations; for an infrequently performed procedure, an open operation is safer.