A hiatal hernia occurs when the upper part of the stomach pushes upward into the chest cavity through a small opening in the diaphragm called the esophageal hiatus. While this condition is relatively common, the majority of cases involve a “sliding” hernia where the junction of the esophagus and stomach moves in and out of the chest. The paraesophageal hiatal hernia is a less common classification. This type involves a portion of the stomach protruding into the chest alongside the esophagus, and it warrants distinct attention due to its potential for severe, sudden complications.
Defining the Condition and Anatomy
The diaphragm is a large, dome-shaped muscle separating the chest cavity from the abdomen, and the esophageal hiatus is the small opening through which the esophagus passes to connect to the stomach. In a paraesophageal hiatal hernia, or Type II hernia, a section of the stomach, most often the fundus, rolls up and sits next to the esophagus within the chest. This anatomical feature defines the condition.
Crucially, the gastroesophageal junction (GEJ), the point where the esophagus meets the stomach, remains in its normal position below the diaphragm in a Type II paraesophageal hernia. This anatomical distinction sets it apart from the far more prevalent sliding hiatal hernia (Type I), where the GEJ itself slides up into the chest. Type I hernias account for approximately 95% of all hiatal hernias. The paraesophageal classification also includes Type III and Type IV hernias, which involve the displacement of both the GEJ and other abdominal organs, but the primary defining feature of the paraesophageal group is the stomach herniating adjacent to the esophagus.
Recognizing Symptoms and Potential Complications
The symptoms associated with a paraesophageal hiatal hernia can be variable, ranging from no noticeable discomfort to severe, debilitating pain. Many individuals experience symptoms such as chest pain, a feeling of rapid fullness after eating, or difficulty swallowing (dysphagia). Chronic, low-level blood loss from erosions in the herniated stomach lining, sometimes called Cameron lesions, can also lead to iron deficiency anemia over time.
The paraesophageal hernia is viewed as a more serious condition than the sliding type due to its potential for severe complications. The fixed nature of the herniated stomach portion makes it susceptible to gastric volvulus, where the stomach twists upon itself. This twisting can lead to a complete obstruction or cut off the blood supply to the tissue, resulting in incarceration or strangulation.
When strangulation occurs, it represents a medical emergency with symptoms that include sudden, intense chest or abdominal pain, retching without vomiting, and an inability to pass a nasogastric tube. This interruption of blood flow causes tissue death and requires immediate surgical intervention. The possibility of these acute events occurring, even in previously asymptomatic patients, is the main reason for close monitoring and proactive treatment.
Diagnostic Confirmation Procedures
Confirming the presence and type of a hiatal hernia often uses the upper gastrointestinal (GI) series, or Barium swallow. This standard method provides a definitive view of the anatomy. During this test, the patient swallows a liquid that coats the digestive tract, allowing the herniated portion of the stomach and the position of the gastroesophageal junction to be clearly visualized on X-ray.
An upper endoscopy uses a thin, flexible tube equipped with a camera passed down the throat into the esophagus and stomach. This allows a physician to directly inspect the stomach lining and the location of the hernia, as well as to check for any signs of inflammation or damage. A Computed Tomography (CT) scan may also be utilized to assess the size of the hernia sac, evaluate surrounding structures, or determine the extent of any acute complications, such as an obstruction.
Treatment Approaches and Surgical Necessity
Unlike the sliding hiatal hernia, which is often managed with lifestyle changes and antacid medications, the paraesophageal type frequently requires surgical correction. This aggressive approach is due to the significant risk of acute, life-threatening complications like gastric volvulus and strangulation. Even if the hernia is not causing severe symptoms, many surgeons recommend elective repair to prevent these future issues.
The goal of surgical intervention is to reduce the herniated stomach back into the abdominal cavity and repair the enlarged opening in the diaphragm. This procedure is most often performed using minimally invasive laparoscopic techniques, which involve small incisions and a quicker recovery time. The surgeon closes the hiatal defect using sutures and often reinforces the repair with a biological or synthetic mesh.
A fundoplication, such as a Nissen fundoplication, is often included in the surgical repair. This involves wrapping the upper part of the stomach around the lower esophagus to create a new barrier against reflux. If the patient presents with an acute complication like an obstruction or strangulation, the procedure becomes an urgent operation. The focus is on relieving the immediate danger, which may involve addressing damaged or compromised stomach tissue.