Paraesophageal Hernia

What is a Paraesophageal Hernia?

A hiatal hernia is a condition in which part of the stomach pokes through the diaphragm and enters the chest cavity. The diaphragm is a muscular wall that normally separates the chest and abdominal cavities. The oesophagus - the tube carrying food after it is swallowed - passes through an opening (hiatus) in the diaphragm to reach the stomach. A paraesophageal hernia is a type of hiatal hernia in which part of the stomach bulges into the chest cavity through the hiatus and remains next to the oesophagus. The junction of the oesophagus and stomach, however, stays in its normal position.

Paraesophageal hernias are fixed as the herniated part of the stomach squeezes against the oesophagus and does not slide back down into the abdominal cavity. They are not as common as the sliding type of hiatal hernias in which the stomach and junction of the oesophagus and stomach slide in and out of the chest cavity.

Causes of Paraesophageal Hernia

Causes of hiatal hernias, including paraesophageal hernias, include:

  • Weakness in the diaphragm due to age
  • Obesity
  • Pregnancy
  • Abdominal trauma
  • Increased pressure in the abdomen due to coughing, or straining during a bowel movement
  • Congenital defect of a large hiatus
  • Hereditary factors

Symptoms of Paraesophageal Hernia

Paraesophageal hernias usually do not produce any symptoms. Since the herniated stomach is fixed and compresses against the oesophagus, there is a risk of constricted blood supply to the stomach and blocking of the oesophagus. Symptoms usually develop in severe conditions and require treatment. These include:

  • Shortness of breath
  • Difficulty swallowing
  • Pain in the chest and abdomen
  • Indigestion 
  • Acid reflux
  • Stomach ulcer
  • Bloating
  • Bleeding within the abdomen
  • Vomiting and nausea

Diagnosis of a Paraesophageal Hernia

Your doctor will review your medical history and symptoms and order certain diagnostic tests such as:

  • CT scan: This scan uses a special x-ray machine to produce clear images of the oesophagus and stomach
  • Barium Swallow test: You will be instructed to drink a small amount of barium liquid which helps visualize the outline of the oesophagus and stomach on X-rays.
  • Endoscopy: This study uses an endoscope, which is a thin flexible tube with a camera and a light attached to its end that is inserted through your throat into the oesophagus.
  • pH monitoring: This test helps detect the acid level in the oesophagus
  • Oesophageal Manometry: This study records oesophagal muscle contraction and its movement while swallowing food

Treatment for Paraesophageal Hernias

In most people, paraesophageal hernias produce no symptoms. Symptoms are usually present only in severe conditions and typically require surgical intervention. 

Laparoscopic surgery is usually chosen. This is a minimally invasive technique where your surgeon makes five or six small incisions on the abdomen through which a laparoscope - a thin flexible tube with a camera and light attached - is inserted, along with other surgical instruments. The camera captures images that are displayed on a monitor to help your doctor guide the instruments during the surgery. Surgery usually includes: 

  • Pulling the herniated portion of the stomach back down into the abdominal cavity
  • Reducing the size of the hiatal opening
  • Fundoplication: The upper part of the stomach, or fundus, is wrapped around the lower portion of the oesophagus to strengthen closure of the sphincter between the oesophagus and stomach. This helps control acid reflux

If the hernia is very large or complicated an open surgery may be performed.

  • The Clementine Churchill Hospital
  • NHS Royal Free London
  • UCL
  • NHS London North West
  • Royal College of Surgeons of England