A paraesophageal hernia (PEH) is a specific type of hiatal hernia where a portion of the stomach protrudes into the chest cavity through the esophageal hiatus, an opening in the diaphragm. This condition is structurally distinct from the more common sliding hiatal hernia. The anatomical differences in a PEH elevate the risk of serious complications, meaning management strategies often differ significantly from other types.
Defining a Paraesophageal Hernia
The diaphragm separates the abdomen and chest, and the esophageal hiatus is the opening through which the esophagus joins the stomach. A hiatal hernia forms when part of the stomach pushes up through this hiatus. In a sliding hernia, the junction between the esophagus and stomach slides into the chest, often causing acid reflux.
A paraesophageal hernia is characterized by the stomach’s fundus—the upper, rounded part—rolling up and lying next to the esophagus. The connection point between the esophagus and stomach generally remains in its normal position below the diaphragm. This structural arrangement is less common but carries a higher potential for mechanical problems.
When the stomach tissue rolls alongside the esophagus, it creates a distinct pocket within the chest. Because the stomach is trapped, there is a risk of the organ twisting on itself, known as gastric volvulus. This mechanical obstruction can restrict the blood supply to the stomach tissue, a complication that makes PEH more serious than the sliding type.
Recognizing the Signs
Symptoms often stem from the mechanical presence of the stomach in the chest, rather than solely from acid reflux. Common complaints include difficulty swallowing, a sensation of food getting stuck, or a feeling of fullness after eating only a small amount. The herniated stomach can also lead to abdominal or chest pain, often exacerbated by meals.
Pressure from a large hernia can compress nearby organs, leading to shortness of breath, particularly after eating. Chronic, slow bleeding from ulcers on the herniated stomach lining, known as Cameron lesions, can cause iron-deficiency anemia over time. These mechanical and obstructive symptoms are typically more pronounced than the heartburn associated with sliding hernias.
Emergency Warning Signs
Certain symptoms indicate a sudden, acute complication requiring immediate medical attention. These signs signal incarceration (stomach tightly trapped) or strangulation (blood supply cut off). Acute, severe chest or upper abdominal pain not relieved by antacids is a serious warning sign.
The inability to vomit or pass a nasogastric tube, along with severe retching, is a classic sign of gastric volvulus, known as Borchardt’s triad. Fever, vomiting, or signs of bleeding, such as passing dark stools or vomiting blood, also suggest tissue damage or obstruction. These acute complications can be life-threatening, making prompt surgical intervention necessary.
Diagnosis and Risk Factors
The diagnostic process begins with a review of the patient’s symptoms, especially those related to mechanical obstruction or severe pain. Imaging studies confirm the diagnosis and determine the hernia’s anatomical type and size. A double-contrast upper gastrointestinal series, or barium swallow, is often the most effective initial test, clearly showing the stomach’s position relative to the diaphragm and esophagus.
An upper endoscopy allows direct visual inspection of the esophagus and stomach lining, helping identify complications like ulcers or inflammation. Computed tomography (CT) scans are utilized, particularly in emergency situations, because they offer superior visualization of the herniated contents and help evaluate for signs of strangulation or ischemia.
Several factors contribute to PEH development by weakening the diaphragmatic tissue or increasing abdominal pressure. Advanced age is a risk factor due to the natural weakening and stretching of tissues. Elevated and sustained abdominal pressure, often caused by obesity, chronic coughing, or repeated straining during bowel movements, can also enlarge the hiatus.
Management and Surgical Repair
Unlike small, asymptomatic sliding hernias managed with lifestyle modifications and antacid medication, a paraesophageal hernia is frequently managed with surgical repair. The risk of severe complications, such as strangulation or volvulus, often outweighs the risks of an elective operation, prompting repair even in minimally symptomatic patients. Conservative management is reserved for patients who are not suitable candidates for surgery due to other serious health conditions.
The standard of care for PEH repair is a minimally invasive approach, typically using laparoscopy. The surgical procedure involves four main objectives:
- Reducing the herniated stomach and other organs back into the abdominal cavity.
- Removing the hernia sac.
- Closing the enlarged hiatus with sutures.
- Reinforcing the repair with a synthetic or biologic mesh.
The surgeon will also perform a fundoplication, where the upper part of the stomach is wrapped around the lower esophagus. This prevents acid reflux and helps secure the stomach in its proper position. This repair, which aims to re-establish the normal anatomy, is performed electively to prevent the need for emergency surgery, which carries significantly higher risks.