A hiatal hernia occurs when an internal organ, typically a portion of the stomach, pushes up through the diaphragm into the chest cavity. The diaphragm is a large, dome-shaped muscle separating the chest from the abdomen. It contains the esophageal hiatus, an opening through which the esophagus passes to meet the stomach. A hiatal hernia develops when this opening stretches, allowing the stomach to protrude. The paraesophageal hiatal hernia is a specific, less common, and generally more serious subtype where the stomach rolls up alongside the esophagus.
Understanding Paraesophageal Hiatal Hernias
Hiatal hernias are categorized into four types. Type I, the most frequent (95%), is a sliding hernia where the gastroesophageal junction and a small part of the stomach intermittently slide up into the chest cavity, often causing acid reflux. Types II, III, and IV are collectively referred to as paraesophageal hernias, meaning “beside the esophagus.”
Type II is the pure paraesophageal form. The upper curve of the stomach (the fundus) rolls up through the hiatus to sit next to the esophagus, while the gastroesophageal junction remains below the diaphragm. Type III is a mixed form where both the junction and a portion of the stomach migrate upward.
Type IV is the most extensive form. It involves a large defect in the diaphragm that allows the entire stomach to herniate. Sometimes, other abdominal organs like the colon, spleen, or small intestine also move into the chest cavity.
Distinctive Symptoms and Urgency
Symptoms associated with paraesophageal hernias relate more to mechanical obstruction than the heartburn seen in sliding hernias. Patients frequently experience feeling full after eating only a small amount of food, nausea, or significant abdominal and chest pain. The stomach’s position in the chest can impede its ability to empty normally, leading to post-meal fullness and difficulty swallowing.
Large hernias can compress nearby structures, causing non-gastrointestinal symptoms such as shortness of breath or chronic cough. Chronic, low-level bleeding from erosions in the stomach lining, known as Cameron lesions, can also occur, leading to iron deficiency anemia.
A paraesophageal hernia can become a medical emergency if the stomach twists (gastric volvulus) or if the herniated tissue becomes incarcerated. Incarceration means the stomach is trapped and squeezed, potentially leading to strangulation if the blood supply is cut off. Acute strangulation causes sudden, severe chest or upper abdominal pain, often accompanied by retching without the ability to vomit, requiring immediate medical attention.
Confirming the Diagnosis
Diagnosis typically begins with a physical examination and imaging studies. The preferred initial method is the Barium Swallow (esophagram). The patient swallows a contrast liquid containing barium, which coats the digestive tract and allows the stomach’s path and shape to be clearly seen on X-ray imaging.
This imaging is effective for distinguishing a paraesophageal hernia from a sliding hernia, as the gastroesophageal junction remains below the diaphragm in the paraesophageal type. Endoscopy (EGD) uses a flexible tube with a camera to examine the mucosal lining of the esophagus and stomach. It is helpful for assessing complications such as erosive esophagitis, ulcers, or bleeding caused by the hernia.
For complicated cases, especially those involving acute symptoms or Type IV hernias, a computed tomography (CT) scan is often necessary. A CT scan provides cross-sectional images that can confirm the presence of other abdominal organs in the chest cavity or detect serious complications like gastric volvulus or strangulation.
Treatment Pathways
Paraesophageal hernias frequently require surgical intervention due to the heightened risk of complications, unlike the Type I sliding hernia managed with medication. Because of the potential for incarceration, obstruction, and strangulation, surgery is often recommended even for patients with mild symptoms. The goals of surgery are to return the herniated stomach and any other organs back into the abdominal cavity and restore normal anatomy.
The procedure involves reducing the hernia by pulling the stomach down through the hiatus. Surgeons then close the enlarged opening in the diaphragm (hiatoplasty), often using sutures to tighten the muscle around the esophagus to prevent recurrence. A fundoplication, such as a Nissen fundoplication, is frequently performed concurrently to anchor the stomach and prevent postoperative acid reflux.
Fundoplication involves wrapping a portion of the stomach (the fundus) around the lower esophagus to create a new valve. A total fundoplication is often the procedure of choice, though a partial fundoplication may be used if the patient has underlying esophageal motility issues. Most repairs are performed using minimally invasive laparoscopic techniques, resulting in shorter recovery times.
Recovery involves a gradual return to normal diet and activity, focusing on managing intra-abdominal pressure to prevent recurrence. Long-term monitoring is necessary to ensure the structural repair remains intact.