What Is Paraesophageal Hiatal Hernia?

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).

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:

• Aging, especially once you're over 50
• Obesity
• Smoking cigarettes
  

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

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:

• Barium X-ray or computed tomography (CT) scan of the upper digestive tract
• Endoscopy (threading a camera on a flexible tube down your throat to look for problems)
  

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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.

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.