Para-esophageal hernia

Last revised by Dr Calum Worsley on 22 Jul 2021

Para-esophageal hernias (POH), or rolling hiatus hernias, are an uncommon type of hiatus hernia representing ~10% of all hiatus hernias. 

Can vary and can include:

  • asymptomatic
  • gastro-esophageal reflux disease 
  • substernal, post-prandial chest pain
  • epigastric pain
  • dysphagia
  • nausea/vomiting
  • obstruction
    • diaphragmatic impingement on the stomach
    • gastric volvulus
    • compression of the esophagus by the intrathoracic stomach
  • respiratory complications
    • associated with a large para-esophageal hernia
    • recurrent aspiration, pneumonia, and chronic cough

In para-esophageal hernia, there is an upward herniation of the gastric fundus above a normally positioned gastroesophageal junction. 

A para-esophageal hernia includes a peritoneal layer that forms a true hernia sac, distinguishing it from the more common sliding hiatus hernia.

In contrast, a sliding hiatus hernia does not have a hernia sac and slides into the chest since the gastro-esophageal junction (GEJ) is not fixed inside the abdomen.

Generally, a hiatus hernia is classified into four types.

  • type I - sliding hernia: GEJ migrates into the posterior mediastinum through the esophageal hiatus
  • type II-IV - para-esophageal hernias:
    • type II: occurs when the fundus herniates through the hiatus above a normally positioned GEJ
    • type III: is a combination of types I and II hernias with a displaced GEJ as well as hernia sac containing portions of the fundus/body of stomach protruding through the hiatus, and the fundus above the level of the GEJ
    • type IV: characterized by the presence of other organs than the stomach (colon, spleen, pancreas and small bowel) into the thorax

Surgical management is indicated when medical management fails to control symptoms of gastro-esophageal reflux that may be related to the para-esophageal hernia, or when there is an emergent complication such as volvulus or obstruction.

According to the Society of American Gastrointestinal and Endoscopic Surgeons 2013 guidelines 5:

  • in the absence of reflux disease, repair of a type I (sliding) hernia is unnecessary
  • all symptomatic paraesophageal hiatus hernias (types II-IV) should be repaired, especially in the presence of acute obstructive symptoms or volvulus

On a chest radiograph, possible considerations include:

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Cases and figures

  • Case 1: combined type
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  • Case 2
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  • Case 3
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  • Case 4
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  • Case 5
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  • Case 6: giant paraesophageal hernia - in a toddler
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  • Case 7
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