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 esophagus - 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 esophagus. The junction of the esophagus and stomach, however, stays in its normal position.
Paraesophageal hernias are fixed as the herniated part of the stomach squeezes against the esophagus 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 esophagus 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
- 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 esophagus, there is a risk of constricted blood supply to the stomach and blocking of the esophagus. Symptoms usually develop in severe conditions and require treatment. These include:
- Shortness of breath
- Difficulty swallowing
- Pain in the chest and abdomen
- Acid reflux
- Stomach ulcer
- 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 esophagus and stomach
- Barium Swallow test: You will be instructed to drink a small amount of barium liquid which helps visualize the outline of the esophagus 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 esophagus.
- pH monitoring: This test helps detect the acid level in the esophagus
- Esophageal Manometry: This study records esophageal 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 esophagus to strengthen closure of the sphincter between the esophagus and stomach. This helps control acid reflux
If the hernia is very large or complicated an open surgery may be performed.