A paraesophageal hernia is a specific type of hiatal hernia where a portion of the stomach bulges upwards into the chest cavity. This occurs near the diaphragm and the esophagus, through a weakened spot in the surrounding muscle or tissue.
Understanding Paraesophageal Hernia
A paraesophageal hernia forms when a part of the stomach, most commonly the upper portion known as the gastric fundus, pushes through the esophageal hiatus, an opening in the diaphragm. Unlike other types of hiatal hernias, in a paraesophageal hernia, the junction where the esophagus meets the stomach usually remains in its normal position below the diaphragm. Instead, a section of the stomach herniates alongside the esophagus into the chest.
This type of hernia is less common than a sliding hiatal hernia, where the stomach and the section of the esophagus that joins it slide up into the chest. Paraesophageal hernias are considered more serious due to a higher potential for complications, such as stomach entrapment or loss of blood supply.
Recognizing the Signs
Paraesophageal hernias can present with a variety of symptoms, though some individuals may experience no symptoms at all. Common symptoms include chest pain, which some patients describe as occurring during or shortly after eating. Difficulty swallowing, known as dysphagia, is another frequent complaint, particularly with solid foods.
Individuals might also experience shortness of breath, especially if a large hernia compresses the lungs or diaphragm. Other indicators can include acid reflux, bloating after meals, and a sensation of feeling full quickly after eating. In some cases, chronic blood loss from the herniated stomach can lead to iron deficiency anemia.
What Causes It
The precise cause of paraesophageal hernias is often unknown. However, it is related to a weakening or enlargement of the esophageal hiatus, the opening in the diaphragm through which the esophagus passes. This weakening can occur over many years due to cumulative stress and strain.
Several factors can contribute to the development or worsening of this condition. Age-related changes in the diaphragm muscles can diminish their strength and elasticity. Increased pressure within the abdomen, such as from chronic coughing, repeated heavy lifting, straining during bowel movements, pregnancy, or obesity, can also play a role. Trauma to the chest or upper abdomen may also predispose an individual to a paraesophageal hernia.
How It’s Diagnosed
Diagnosis involves several tools. A barium swallow, also known as an esophagram or upper GI series, is often the preferred initial test. This involves drinking a liquid containing barium, which coats the esophagus and stomach, allowing their structure and any herniation to be visualized on X-rays. This test shows the dynamic movement of the stomach and esophagus and the extent of the herniation.
An upper endoscopy (EGD) involves inserting a flexible tube with a camera down the throat to directly view the esophagus and stomach. This procedure assesses the lining of these organs and identifies complications like inflammation or ulcers. A CT scan provides detailed cross-sectional images, documenting the hernia’s size and contents, especially if other organs are involved. Esophageal manometry measures the pressure and movement of esophageal muscles, providing information about esophageal function.
Treatment Approaches
Treatment involves non-surgical and surgical strategies. For individuals with mild symptoms or smaller hernias, lifestyle modifications and medications are suggested. Dietary adjustments, such as eating smaller meals and avoiding trigger foods, can help alleviate symptoms. Weight management and elevating the head of the bed during sleep can also reduce discomfort. Medications like antacids or proton pump inhibitors (PPIs) can help control acid reflux.
However, due to the potential for serious complications like stomach twisting or obstruction, surgery is frequently recommended for symptomatic paraesophageal hernias. The goal of surgery is to return the herniated stomach to its normal position in the abdomen and to close the enlarged opening in the diaphragm. Laparoscopic repair, a minimally invasive technique, is commonly used, involving small incisions and a camera to guide the surgeon. Often, a fundoplication, which involves wrapping a part of the stomach around the lower esophagus, is performed concurrently to reinforce the lower esophageal sphincter and reduce acid reflux. The decision for surgery and the specific technique chosen depend on the hernia’s size, the severity of symptoms, and the presence of complications.