Paraoesophageal hernia
A paraoesophageal hernia is a hiatus hernia in which part of the stomach herniates into the chest alongside the oesophagus, rather than the junction simply sliding upward. It is far less common than the sliding hernia but considerably more important, because it can twist, obstruct or strangulate. Large hernias are a mechanical problem rather than an acid problem, and they are treated surgically for that reason.
How it forms
The oesophagus passes into the abdomen through the diaphragmatic hiatus, anchored by the phreno-oesophageal membrane. With age, repeated raised abdominal pressure, obesity, straining and chronic cough, this membrane attenuates and the hiatus widens.
In a sliding (type I) hernia the gastro-oesophageal junction itself migrates upward. In a paraoesophageal (type II) hernia the junction remains anchored below the diaphragm while the gastric fundus rolls up through the widened hiatus beside the oesophagus. Type III is a mixed hernia, with both an elevated junction and a rolled-up fundus, and is the pattern most often seen in practice. Type IV contains other organs — colon, spleen, pancreas or small bowel — within the hernia sac.
Once a portion of stomach sits within the chest, it can rotate. The stomach twists either around its long axis (organoaxial) or around a line from lesser to greater curve (mesenteroaxial). Volvulus obstructs the stomach and, if rotation is sufficient, compromises its blood supply. This is the mechanism behind the serious complications, and the reason a large hernia is not simply a bigger version of a small one.
A giant hernia in which most of the stomach lies in the chest, often inverted, is termed an intrathoracic or "upside-down" stomach.
Symptoms
Many are discovered incidentally on a chest X-ray or CT performed for another reason. When symptomatic, the features are mechanical rather than acid-related:
- chest or upper abdominal discomfort, often after eating
- early satiety and inability to finish a meal
- postprandial breathlessness, as the hernia limits lung expansion
- dysphagia
- regurgitation of undigested food
- iron-deficiency anaemia — from Cameron lesions, linear erosions where the stomach is compressed at the hiatus. This is an important and easily missed presentation: unexplained anaemia in an older patient with a known hernia deserves attention.
- palpitations, from cardiac compression
Acute presentation — gastric volvulus — produces severe chest or epigastric pain, retching without productive vomiting, and inability to pass a nasogastric tube. This triad (Borchardt) is a surgical emergency.
How the diagnosis is made
Chest X-ray may show a retrocardiac gas-fluid level. Barium swallow demonstrates the anatomy dynamically and shows the position of the gastro-oesophageal junction and any rotation. CT defines the size, the contents and the anatomy, and is the investigation of choice in the acute setting.
Endoscopy assesses the mucosa, identifies Cameron lesions and excludes other pathology. Manometry is performed before elective repair where possible, to guide whether and what type of fundoplication to add — though it is often technically difficult in a large hernia.
When surgery is indicated
This has changed and it is worth being clear about. Historically all paraoesophageal hernias were repaired because of a presumed high risk of catastrophic complication. That risk is now understood to be considerably lower than once thought, and the current position is:
- Symptomatic hernias should be repaired in patients fit for surgery.
- Acute volvulus or obstruction requires emergency surgery.
- Anaemia attributable to Cameron lesions is an indication.
- Truly asymptomatic hernias in elderly or frail patients may reasonably be observed, since the annual risk of acute complication is low and the operation carries real risk in that group.
This is a genuinely individualised decision. A large hernia in a fit 60-year-old with early satiety and breathlessness is a clear indication; the same hernia found incidentally in a frail 85-year-old with cardiac disease usually is not.
Surgery
Repair follows defined steps, and the quality of each determines durability:
- Complete reduction of the stomach and any other contents into the abdomen.
- Excision of the hernia sac from the mediastinum — essential, and the step most often done inadequately.
- Extensive mediastinal oesophageal mobilisation to achieve at least 2–3cm of tension-free intra-abdominal oesophagus. Where this cannot be achieved, a Collis gastroplasty lengthens the oesophagus.
- Crural closure, with or without mesh reinforcement.
- Fundoplication, which both controls reflux and anchors the stomach below the diaphragm.
Mesh use remains debated: it reduces early radiological recurrence but has not been shown convincingly to improve symptoms long-term, and erosion into the oesophagus, though rare, is a serious complication. Biological and absorbable meshes are used selectively rather than routinely.
Most repairs are performed laparoscopically or robotically. Recurrence, usually radiological and often asymptomatic, is common after large hernia repair, and patients should be told this honestly: the aim is durable symptom relief, not a permanently perfect anatomical result.
Recovery
Hospital stay is typically two to four days. A soft diet is followed for several weeks. Patients are advised to avoid heavy lifting and straining for six to eight weeks, and to treat constipation and cough actively, since raised abdominal pressure is what caused the problem in the first place.
Common questions
My scan shows part of my stomach in my chest. Is that serious?
It needs proper assessment rather than alarm. Many such hernias cause no trouble for years. What matters is whether you have symptoms — feeling full quickly, breathlessness after eating, chest discomfort, difficulty swallowing or unexplained anaemia — and how fit you are for an operation.
Do all large hiatus hernias need surgery?
No. If it causes no symptoms and you are elderly or have significant other medical problems, observation is often the wiser course. The risk of a sudden serious complication is lower than was once believed. If it causes symptoms and you are fit, repair is generally advised.
What is the emergency I should watch for?
Sudden severe chest or upper abdominal pain with retching but inability to vomit, and inability to swallow, suggests the stomach has twisted. This requires immediate hospital attention.
Why am I anaemic?
Where the stomach is squeezed at the diaphragm, small linear ulcers can form and bleed slowly. This is a recognised cause of iron deficiency in people with large hernias, and it is often overlooked because the bleeding is not visible.
Can the hernia come back after repair?
Some degree of recurrence on scans is common after repair of a large hernia, though many recurrences cause no symptoms and need nothing. The aim of the operation is lasting relief of symptoms. Avoiding heavy lifting, treating constipation and cough, and losing weight all help protect the repair.
Will I need mesh?
Sometimes. Mesh can strengthen the closure of a large diaphragmatic opening, but it carries its own uncommon risks and the long-term benefit is not clear-cut. It is used selectively, according to the size of the defect and the quality of the tissues.
Related conditions
Other conditions of the oesophagus covered on this site:
- Gastro-oesophageal reflux disease (GORD) and hiatus hernia
- Achalasia
- Barrett's oesophagus
- Oesophageal diverticulum (Zenker's and epiphrenic)
- Benign tumours of the oesophagus
- Oesophageal cancer
- Oesophageal perforation and Boerhaave syndrome
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history, examination and imaging.