What Is Paraesophageal Hiatal Hernia?

A condition that causes chest pain, swallowing problems, and more

A paraesophageal hernia is when part or all of an abdominal organ pushes into your chest through an opening in the diaphragm so that it is now positioned next to your esophagus.

Though the rarer of the two types of hiatal hernia, it is potentially more serious. Some cases have no symptoms and may not need to be treated, but those that do require surgery to manage complications such as a loss of the herniated organ's blood supply.

The article explains how paraesophageal hernia compares to the more common type, sliding hernia. It also discusses possible symptoms, causes, diagnosis, and treatment of paraesophageal hernia.

What's Happening in the Body

When you have a hernia, it means part or all of an internal organ has been pushed into an area where it doesn't belong.

More specifically, part of the abdomen (which contains your stomach, intestines, and several other organs) pushes into the chest cavity (which houses the heart and lungs) through the diaphragm, a sheet of muscle that normally separates these areas.

Paraesophageal Hernia vs. Sliding Hernia

The esophagus is the swallowing tube between your mouth and stomach. It travels through an opening in the diaphragm called the hiatus.

The gastroesophageal (GE) junction is where the esophagus and the stomach meet.

When you swallow, the esophagus shortens and lengthens. Sometimes, this motion pulls a part of the stomach or the GE junction up through the hiatus.

Which of these occurs dictates the type of hiatal hernia you have: sliding (type 1) or paraesophageal (types 2 through 4).

Sliding Hernia
  • The GE junction moves up through the hiatus

  • The junction moves up and down (slides) through the hiatus

  • More common, less serious

Paraesophageal Hernia
  • Abdominal organ squeezes through the hiatus and into the chest

  • The herniated organ is stuck in the chest next to the esophagus

  • Less common, more serious

What Causes a Paraesophageal Hernia?

Why hernias occur is not well understood, but weak supporting tissues may to blame.

Other possibilities include things that damage or put chronic, excessive pressure on related muscles. These include:

  • Injury and trauma
  • Chronic coughing
  • Lifting heavy objects
  • Vomiting repeatedly
  • Straining to move your bowels

Factors that increase your risk for a paraesophageal hernia include:

Symptoms of a Paraesophageal Hernia

Paraesophageal hernias often don't cause any symptoms. However, if you do have symptoms, they can be serious and may lead to complications.

Symptoms of paraesophageal hernia can include:

  • Sudden severe chest pain
  • Radiating chest pain that isn't relieved by antacids
  • Difficulty swallowing
  • Stomach pain
  • Indigestion (dyspepsia)
  • Nausea
  • Vomiting
  • Retching (dry heaves)

If a paraesophageal hernia is detected, it should be routinely checked whether it is currently causing symptoms or not.

Complications

complications of paraesophageal hernia

Verywell / Laura Porter

Paraesophageal hernias are considered more serious than sliding hernias because of their potential for complications, which include:

  • Incarceration: The stomach is squeezed or constricted, which can lead to strangulation.
  • Strangulation: The blood supply to the portion of the stomach is cut off, which kills the tissues. 
  • Bleeding: Erosions and ulcers (sores) called Cameron lesions develop and slowly bleed, leading to anemia.
  • Gastric volvulus: The stomach twists, which can cause problems swallowing, pain just below the ribs, and retching.
  • Breathing problems: A large hernia may put pressure on your lungs so they can't fully expand.

Diagnosis

To diagnose a paraesophageal hernia, your healthcare provider will ask you about your symptoms and give you a physical examination. They may order tests as well, such as:

Hiatal Hernia Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Doctor Discussion Guide Woman

Treatment

Any paraesophageal hernias that cause symptoms or complications need to be treated with surgical repair.

Emergency surgery will be done if there are signs of:

  • Bleeding that can't be stopped
  • Breathing problems
  • Stomach twisting
  • Incarceration
  • Strangulation

How Hernia Surgery Is Done

Hiatal hernia surgery is commonly done as a laparoscopic procedure. A laparoscope is a thin, telescope-like instrument with a camera on the end that lets the surgeon see the inside of your abdomen.

For this procedure, the surgeon makes several small incisions in your abdomen so they can insert instruments. They use those to ease your stomach (or other herniated organ) down through the hiatus.

They then close the hiatus so the stomach doesn't move back up through it. Sometimes, they'll use a special mesh for that.

The top of the stomach is often wrapped around the lower portion of the esophagus as well, which also prevents re-herniation.

The outcome of most hiatal hernia surgeries is excellent and generally results in few complications. You should only expect to be in the hospital for a day or two. Most people can get back to their usual lifestyle within about four weeks of surgery.

Summary

A paraesophageal hernia occurs when all or part of the stomach or another abdominal organ squeezes through the hiatus and into the chest cavity, next to the esophagus.

If the paraesophageal hernia causes symptoms, they can include severe chest pain, problems swallowing, stomach pain, and vomiting or retching. Complications can include strangulation (loss of blood supply), a twisted stomach, bleeding ulcers, and breathing problems.

Symptomatic paraesophageal hernias need to be treated with surgery to put the herniated organ back where it's supposed to be and close the hiatus so it can't herniate again.

Frequently Asked Questions

  • How long can you live with a paraesophageal hernia?

    If your paraesophageal hernia never causes symptoms or complications, you can live with it forever. Once it becomes symptomatic, you need to have surgery.

  • What is a type 4 paraesophageal hernnia?

    A type 4 hiatal hernia is the most severe kind. It involves the stomach and other abdominal organs moving up into the chest cavity. They're rare, accounting for less than 5% of hiatal hernias.

  • How do I know if my hiatal hernia is strangulated?

    Symptoms of a strangulated hiatal hernia include:

    • Severe chest pain
    • Heart palpitations
    • Shortness of breath
    • Nausea
    • Bloating
    • Difficulty swallowing

    This is a medical emergency. Call 911 or get to an emergency room right away.

7 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Medical College of Wisconsin. Paraesophageal hernia (hiatal hernia).

  2. University of Pennsylvania: PennMedicine. Hiatal hernia.

  3. Johns Hopkins Medicine. Hiatal hernia.

  4. Chang CC, Tseng CL, Chang YC. A surgical emergency due to an incarcerated paraesophageal herniaAm J Emerg Med. 2009;27(1):134.e1-134.e3. doi:10.1016/j.ajem.2008.05.009

  5. Yang X, Hua R, He K, Shen Q, Yao Q. Laparoscopic hernioplasty of hiatal herniaAnn Transl Med. 2016;4(18):343. doi:10.21037/atm.2016.09.03

  6. Patel S, Yarra S, Owji S, Benavidez JE, Nguyen QD. Minding the gap: Clinical manifestations of a rare type IV hiatal herniaCureus. 2020;12(7):e9275. Published 2020 Jul 19. doi:10.7759/cureus.9275

  7. Harvard Medical School, Harvard Health Publishing. Hiatal hernia.