What is Paraesophageal Hernia: Causes, Stages, Symptoms, Treatment, Prognosis, Prevention

Hernia is defined as an abnormal medical condition where one part of the body pushes into another part of the body. Hiatal hernia is a type of hernia that occurs in the stomach area; i.e. when the tissues of the stomach pushes through the opening in the diaphragm called as hiatus. This area is reserved for the oesophagus. Based on the position of the stomach, hiatal hernia is classified into 2 types as described below:

• Sliding Hiatal Hernia: A condition where the stomach pushes through the oesophagus opening and then slides back.
• Paraesophageal Hernia: A condition where the stomach remains where it belongs.

Paraesophageal hernia is a type of hiatal hernia where the gastro-oesophageal junction is at the level of diaphragm, and a portion of the stomach pushes into the chest area beside the oesophagus. It is a type of hernia that remains in the chest area without affecting swallowing. However, in cases of large paraesophageal hernia, there may be compression of the oesophagus which in turn affects the passage of food into the stomach. This may cause sticking of food in the oesophagus post swallowing. It may also lead to development of ulcers in the herniated stomach due to irritation from the food or acidity in the stomach. These types of large paraesophageal hernia are rare. Paraesophageal hernia is often present without any symptoms. Pain and discomfort is felt when the hiatus strangles the stomach.

As mentioned earlier, a large number of individuals affected by paraesophageal hernia do not experience any symptoms. Studies have shown that about 50% of the cases experience the symptoms. As a result, majority of the cases of paraesophageal hernia go undiagnosed and does not receive any treatment. In some cases, the symptoms are mistaken for other conditions such as acid reflux and heart burn. In advanced cases, paraesophageal hernia may present itself with intense pain and discomfort which requires immediate medical attention. The most commonly encountered symptoms of paraesophageal hernia include:

• Chest pain or heart burn that does not subside with antacid
• Swallowing difficulty
• Shortness of breath
• Abdominal pain or discomfort
• Indigestion
• Vomiting
• Nausea.

Paraesophageal hernia can be divided into 4 stages based on the severity or phase of the condition. These stages are described below:

• Stage 1: The first stage of paraesophageal hernia is called as sliding hernia where the stomach pushes through the diaphragm into the chest and slides back.
• Stage 2: The second stage is called as paraesophageal hernia where the hernia stays in the chest instead of going back to its normal position. This phase often remains asymptomatic.
• Stage 3: The third stage of this condition is a combination of the above 2 stages. The stomach remains above the hiatus but slides back to the correct position.
• Stage 4: In this last stage the entire stomach and the organs including colon and spleen are pushed into the chest cavity. This is a very uncommon and rare stage.

The exact cause of paraesophageal hernia is unclear at the moment. A large number of researches are being carried out to understand this condition closely. It has been noted that a large number of cases are associated with GERD or gastro-esophageal reflux disease. The most probable causes of paraesophageal hernia are mentioned below:

• Presence of a hiatal opening since birth
• Weakness in the abdominal wall since birth
• Weight gain during pregnancy or obese condition leads to extra pressure over abdomen
• Excessive coughing or excessive straining during bowel movement also causes stress build up over the abdomen
• The condition worsens with aging
• History of previous abdominal surgery.

In most of the cases, the diagnostic tests are suggested once the condition is symptomatic. Diagnosis includes obtaining a thorough case history followed by physical examination. The area is physically examined to look for hernia while asking the patient to cough. Specialized tests such as barium swallow test are often helpful. This involves drinking a chalky liquid followed by an x-ray. Endoscopy is also done to diagnose the condition. Endoscopy is a study where an endoscope or a small tube with a camera on one end is introduced through the mouth into the digestive tract.

Paraesophageal hernia when diagnosed and treated on time, the prognosis is good. It has been noted that paraesophageal hernia affects women more than men, which is possibly due increased pressure over the abdomen during pregnancy. It generally affects individuals after the 50 years of age. Paraesophageal hernia accounts for only about 5% of hiatal hernia in total. In about 10% of cases, there may be recurrence.

In some cases, the condition heals by itself and does require any treatment. In case the condition is symptomatic, active treatment is warranted. In most of the cases, surgical repair is recommended. A delay in surgery can cause strangulation or constriction, which may lead to complete cut off from blood supply to the area. In the recent times, laparoscopic (minimally invasive) surgery has replaced conventional surgery considering the advantages associated with it. A laparoscopic instrument is used to enter the abdomen through a small incision (5 to 10 mm). The surgery aims at repositioning the stomach and reinforcing the hiatus. The laparoscope transmits a picture of the internal organ and helps the surgeon to carry out the surgery. The advantage of this surgery is requirement of smaller incision lesser risk of infection, less post-operative pain, less chances of scarring, and rapid recovery.

Other treatment includes:

• Dietary Modification: It is recommended to follow a diet that is rich in fibre and is easy to digest. It is also advised to avoid spicy and acidic food. Affected individual should limit intake of alcohol, quit smoking and avoid over eating.
• Medications: Medications such as antacids and H2 blockers are often helpful. They help in reducing the acidity of the stomach and help the stomach to empty its content more quickly.

Though the exact cause of the condition is yet unknown, a few preventive measures are recommended to avoid this condition. In individuals, who are suspected to develop this condition in future a preventive surgery is recommended to repair the condition before the complications take over. Dietary modifications and lifestyle changes are helpful. The following preventive measures are often recommended:

• Weight loss or maintenance of reasonable weight
• Following a fibre rich diet
• Avoiding spicy and acidic food from diet
• Eating smaller meals
• Avoid straining while bowel movement
• Avoid activities such as heavy lifting
• Exercise regularly and follow a healthy lifestyle

Paraesophageal hernia is a type of hiatal hernia. It is a rare condition that often goes undiagnosed until symptomatic. It is often mistaken for other gastro intestinal condition such as GERD. The symptoms include abdominal pain, acid reflux, difficulty swallowing, shortness of breath etc. Diagnosis is often done by physical examination supported by specialized tests such as endoscopy and barium swallow test. Treatment of this condition involves dietary modification and lifestyle modification. Medications are helpful in controlling acidity. In advanced cases, laparoscopic surgery is considered. The prognosis of this condition is excellent provided the condition is detected and treated on time.

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