Paraesophageal hernia

Paraesophageal hernia is a specific form of hiatal hernia, in which a part of the stomach displaces into the chest cavity alongside the esophagus, while maintaining the normal position of the gastroesophageal junction. This condition is classified as so-called type II and III hernias, and its clinical significance results from the risk of mechanical complications, such as incarceration or gastric volvulus. Paraesophageal hernia occurs less frequently than sliding hernia, however, its course can be more complex and requires detailed diagnostics and often surgical treatment.

Paraesophageal hernia – symptoms

Symptoms of paraesophageal hernia are varied and depend on the degree of organ displacement, the size of the hernia, and the presence of complications. In the initial stages, the condition may be asymptomatic, and its diagnosis is often incidental during imaging tests.

As the disease progresses, symptoms arise resulting from both the compression of mediastinal structures and gastrointestinal motility disorders:

a feeling of fullness in the epigastrium and early satiety after meals,
chest pain, often mistaken for cardiac complaints,
shortness of breath and a feeling of pressure in the chest, especially after eating,
difficulty swallowing (dysphagia) resulting from esophageal compression,
recurrent belching and nausea,
anemia caused by chronic micro-bleeding from the gastric mucosa.

In contrast to a sliding hernia, symptoms of gastroesophageal reflux may be less intense, although they sometimes also occur. Particularly clinically significant are acute symptoms suggesting complications:

sudden, severe chest or epigastric pain,
vomiting and the inability to pass gas,
symptoms of gastrointestinal obstruction.

Such manifestations may indicate gastric volvulus or its incarceration, which is a life-threatening condition and requires urgent surgical intervention.

Paraesophageal hernia – diagnostic imaging

Diagnosis of paraesophageal hernia is based primarily on imaging studies, which enable the assessment of stomach location, the degree of organ displacement, and the identification of possible complications. Proper selection of diagnostic methods is of key importance, as the clinical picture can be nonspecific.

Basic tests include:

Contrast X-ray of the esophagus and stomach (barium study) – considered one of the most sensitive tests in the diagnosis of hiatal hernias; it allows for visualizing the displacement of part of the stomach into the chest and assessing its mobility and possible torsion,
gastroscopy (upper gastrointestinal endoscopy) – enables direct assessment of the esophageal and gastric mucosa, detection of erosions, ulcers, and sources of bleeding, as well as indirect diagnosis of the hernia,
computed tomography (CT) – particularly useful in complicated cases; allows for a precise assessment of anatomical relationships, the presence of incarceration, gastric volvulus, or compression of mediastinal structures,
magnetic resonance imaging (MRI) – used less frequently, but helpful in assessing soft tissues and in situations requiring accurate differential diagnosis.

Functional tests are also used complementarily:

esophageal manometry – assessment of esophageal motility and the function of the lower esophageal sphincter,
24-hour pH monitoring – analysis of the presence and severity of gastroesophageal reflux.

Imaging diagnostics play a key role not only in the diagnosis of paraesophageal hernia but also in qualification for surgical treatment. It allows for determining the size of the hernia, the risk of complications, and selecting the optimal surgical technique. In clinical practice, a combination of several diagnostic methods is often used, which increases the accuracy of diagnosis and the safety of further therapeutic management.

Paraesophageal hernia – treatment

Therapeutic management of paraesophageal hernia depends on the stage of the disease, the presence of symptoms, and the risk of complications. Unlike a sliding hernia, conservative treatment has limited application.

In the case of small, asymptomatic hernias, observational management is possible, including:

regular gastroenterological check-ups,
lifestyle modification (avoiding heavy meals, weight reduction),
pharmacological treatment in case of coexisting reflux (proton pump inhibitors).

However, in most cases, especially in the presence of symptoms or large hernias, surgical treatment is the method of choice. The goal of the procedure is:

reduction of the displaced stomach into the abdominal cavity,
closure of the esophageal hiatus of the diaphragm,
reinforcement of the anti-reflux barrier (most often through fundoplication).

Currently, the standard is minimally invasive surgery (laparoscopic), which allows for:

shortening of hospitalization time,
reduction of the risk of postoperative complications,
faster return to activity.

In selected cases, techniques using synthetic meshes to reinforce the esophageal hiatus are also used, especially in large diaphragmatic defects.

Untreated paraesophageal hernia can lead to serious complications, such as:

gastric ischemia and necrosis,
gastrointestinal perforation,
severe anemia.

For this reason, proper qualification for surgical treatment is crucial in preventing the consequences of the disease.