Paraoesophageal hernias (POH), or rolling hiatus hernias, are an uncommon type of hiatus hernia representing ~10% of all hiatus hernias.
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Clinical presentation
Can vary and can include:
asymptomatic
substernal, post-prandial chest pain
epigastric pain
nausea/vomiting
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obstruction
diaphragmatic impingement on the stomach
compression of the oesophagus by the intrathoracic stomach
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respiratory complications
associated with a large paraoesophageal hernia
recurrent aspiration, pneumonia, and chronic cough
Pathology
In paraoesophageal hernia, there is an upward herniation of the gastric fundus and/or antrum above a normally positioned gastro-oesophageal junction.
A paraoesophageal 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-oesophageal junction (GOJ) is not fixed inside the abdomen.
Classification
Generally, a hiatus hernia is classified into four types.
type I - sliding hernia: GOJ migrates into the posterior mediastinum through the oesophageal hiatus
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type II-IV - paraoesophageal hernias:
type II: occurs when the fundus herniates through the hiatus above a normally positioned GOJ
type III: is a combination of types I and II hernias with a displaced GOJ 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 GOJ
type IV: characterised 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-oesophageal reflux that may be related to the paraoesophageal 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 paraoesophageal hiatus hernias (types II-IV) should be repaired, especially in the presence of acute obstructive symptoms or volvulus.
Complications
oesophageal dilatation and aspiration pneumonia
Differential diagnosis
On a chest radiograph, possible considerations include:
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