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Paraesophageal hernia

Last revised by Andrea Molinari ◉ on 14 May 2024

Citation, DOI, disclosures and article data

Citation:

Fam M, Molinari A, Weerakkody Y, et al. Paraesophageal hernia. Reference article, Radiopaedia.org (Accessed on 17 Mar 2025) https://doi.org/10.53347/rID-25474

DOI:

https://doi.org/10.53347/rID-25474

Permalink:

https://radiopaedia.org/articles/25474

rID:

25474

Article created:

27 Oct 2013, Maged Fam

Disclosures:

At the time the article was created Maged Fam had no recorded disclosures.

View Maged Fam's current disclosures

Last revised:

14 May 2024, Andrea Molinari ◉

Disclosures:

At the time the article was last revised Andrea Molinari had no financial relationships to ineligible companies to disclose.

View Andrea Molinari's current disclosures

Revisions:

25 times, by 18 contributors - see full revision history and disclosures

Systems:

Gastrointestinal, Chest

Synonyms:

Rolling (para-oesophageal) hiatus hernia
Rolling hiatus hernia
Paraesophageal hernias
Paraesophageal herniation
Paraoesophageal hernia
Paraesophageal hernia (PEH)
Paraoesophageal hernia (POH)
Paraesophageal hernia
Paraesophageal hiatal hernia
Para-oesophageal hernia
Paraoesophageal hiatal hernia
Paraoesophageal hiatal hernias
Rolling hiatal hernia
Rolling hiatal hernias

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

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 paraesophageal hernia
- recurrent aspiration, pneumonia, and chronic cough

Pathology

In paraesophageal hernia, there is an upward herniation of the gastric fundus and/or antrum above a normally positioned gastro-esophageal junction.

A paraesophageal 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.

Types

Generally, a hiatus hernia is subdivided into four types ¹³ :

type I - sliding hernia: GEJ migrates into the posterior mediastinum through the esophageal hiatus
type II-IV - paraesophageal 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 and/or 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

Treatment and prognosis

Surgical management is indicated when medical management fails to control symptoms of gastro-esophageal reflux that may be related to the paraesophageal 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.

Complications

esophageal dilatation and aspiration pneumonia
gastric necrosis
gastric volvulus

Differential diagnosis

On a chest radiograph, possible considerations include:

Quiz questions

References

1. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22 (4): 601-16. doi:10.1016/j.bpg.2007.12.007 - Free text at pubmed - Pubmed citation
2. Skinner DB. Hernias (hiatal, traumatic, and congenital) In: Berk JE, editor. Gastroenterology. Vol. 4. W. B. Saunders; Philadelphia: 1985. pp. 705–716. Chapter 53.
3. Coughlin M, Fanous M, Velanovich V. Herniated pancreatic body within a paraesophageal hernia. World J Gastrointest Surg. 2011;3 (2): 29-30. doi:10.4240/wjgs.v3.i2.29 - Free text at pubmed - Pubmed citation
4. Dunn DB, Quick G. Incarcerated paraesophageal hernia. Am J Emerg Med. 1990;8 (1): 36-9. Pubmed citation
5. Kohn GP, Price RR, Demeester SR, et al. Guidelines for the management of hiatal hernia. Available at http://www.sages.org/publications/guidelines/guidelines-for-the-management-of-hiatal-hernia. Accessed July 9, 2013.
6. Diaphragm. In: Surgical Foundations: Essentials of thoracic surgery, Kaiser, LR, Singal, S. (Eds), Elsevier Mosby, Philadelphia 2004. p.294. Kaiser L, Singhal S. Surgical foundations. Mosby. ISBN:0815126131. Read it at Google Books - Find it at Amazon
7. Miller, JI, Jr. Chapter 89. Bacterial infections of the lungs and bronchial compressive disorders. In: General thoracic surgery. Lippincott Williams & Wilkins. ISBN:0781779820. Read it at Google Books - Find it at Amazon
8. Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation?. Ann. Surg. 2002;236 (4): 492-500. Free text at pubmed - Pubmed citation
9. Skinner D & Belsey R. Surgical Management of Esophageal Reflux and Hiatus Hernia. Long-Term Results with 1,030 Patients. J Thorac Cardiovasc Surg. 1967;53(1):33-54. - Pubmed
10. Hill L. Incarcerated Paraesophageal Hernia. A Surgical Emergency. Am J Surg. 1973;126(2):286-91. doi:10.1016/s0002-9610(73)80165-5 - Pubmed
11. Terrence M. Fullum. Surgical Approach, Risks, and Outcomes Of Paraesophageal Hiatal Hernia Repair: An Analysis Of The National Inpatient Sample Database [Internet]. Charlotte,NC: Surgical Section of the National Medical Association July 26, 2011. Available from: http://www.nma-surgical.org/files/Annual_Scientific_Symposium_2011/Fullum_SSNMA_2011.pdf
12. Stephens M & Hughes A. Paraoesophageal Omental Hernia. Case Reports. 2013;2013(jul26 1):bcr2013009683. doi:10.1136/bcr-2013-009683 - Pubmed
13. Kahrilas P, Kim H, Pandolfino J. Approaches to the Diagnosis and Grading of Hiatal Hernia. Best Pract Res Clin Gastroenterol. 2008;22(4):601-16. doi:10.1016/j.bpg.2007.12.007 - Pubmed

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