A paraesophageal hernia is a type of hiatal hernia in which part of the stomach pushes up through the diaphragm and into the chest cavity, sitting next to the esophagus. Unlike the far more common “sliding” hiatal hernia, where the junction between the esophagus and stomach slides upward, a paraesophageal hernia involves the stomach bulging through a widened opening in the diaphragm while that junction often stays in its normal position. These hernias account for roughly 1% of all hiatal hernias, but they deserve attention because they can grow over time and, in rare cases, lead to serious complications.
How It Differs From a Sliding Hiatal Hernia
Hiatal hernias are classified into four types based on what moves and where it goes. Type I, the sliding hernia, makes up about 99% of cases. In a sliding hernia, the stomach and the gastroesophageal junction (where the esophagus meets the stomach) both slide upward through the diaphragm’s natural opening, called the hiatus. This is the kind most people have when they’re told they have a hiatal hernia, and it’s closely linked to acid reflux.
Types II through IV are all paraesophageal hernias, and they behave differently:
- Type II (pure paraesophageal): Part of the stomach, typically the upper portion called the fundus, rolls up alongside the esophagus into the chest. The gastroesophageal junction stays below the diaphragm where it belongs.
- Type III (mixed): A combination of sliding and paraesophageal. Both the gastroesophageal junction and a portion of the stomach migrate into the chest. This is the most common type among paraesophageal hernias.
- Type IV (giant): The rarest form, occurring in about 0.1% of all hiatal hernias. A large portion of the stomach, and sometimes other organs like the colon, small intestine, or spleen, herniates into the chest.
What Causes the Stomach to Shift
The diaphragm has a small opening (the hiatus) that the esophagus passes through on its way to the stomach. A band of connective tissue anchors the esophagus in place at this opening. Over time, this tissue and the surrounding muscle of the diaphragm can weaken and stretch, widening the hiatus enough for the stomach to push through. The exact trigger isn’t fully understood, but the result is a structural failure: the opening that should be just big enough for the esophagus becomes large enough to accommodate part of the stomach.
Paraesophageal hernias are most common in older adults, particularly women. Kyphosis, the forward curvature of the upper spine that becomes more common with age, is a major risk factor. People who have had other types of hernias, such as inguinal, umbilical, or ventral hernias, also face higher risk, suggesting that a general tendency toward connective tissue weakness plays a role. That said, these hernias are increasingly seen in younger people and men as well.
Symptoms to Recognize
Small paraesophageal hernias sometimes cause no symptoms at all and are discovered incidentally on imaging done for another reason. When symptoms do appear, they tend to reflect the mechanical reality of a stomach that’s partially sitting in the chest where it doesn’t belong.
Common symptoms include chest pain or pressure behind the breastbone (retrosternal pain), heartburn, and early satiety, the feeling of being full after eating only a small amount. Some people experience difficulty swallowing, nausea after meals, or shortness of breath, especially when lying down, because the herniated stomach can press against the lungs. The symptoms often worsen after eating, since a full stomach takes up more space in the chest.
The most serious potential complication is gastric volvulus, where the herniated stomach twists on itself. This can cut off blood supply and is a surgical emergency. Volvulus is uncommon but represents the primary reason doctors take large paraesophageal hernias seriously even when day-to-day symptoms seem manageable.
How It’s Diagnosed
Three imaging tools are used to identify and characterize paraesophageal hernias: barium swallow studies, CT scans, and endoscopy (a camera passed down the esophagus). A barium swallow, where you drink a contrast liquid while X-rays are taken, has 100% sensitivity for detecting that a hiatal hernia exists. Endoscopy is nearly as sensitive at about 98%.
Detecting that a hernia is present, however, is different from pinpointing exactly what type it is. Both barium swallow and endoscopy are surprisingly unreliable at distinguishing a paraesophageal hernia from a sliding one. Barium swallow correctly identifies the hernia type only about 39% of the time, and endoscopy gets it right in fewer than 9% of cases. When the type of hernia needs to be confirmed, a CT scan of the chest and upper abdomen with the stomach adequately distended provides the clearest picture, showing both the position of the stomach and whether any other organs have herniated alongside it.
When Surgery Is Recommended
Management depends on the hernia’s size, type, and the severity of symptoms. If you have a paraesophageal hernia that causes significant symptoms like chest pain, difficulty eating, or breathing problems, surgical repair is generally recommended. The decision gets more complicated for hernias that aren’t causing noticeable problems. Guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons acknowledge that deciding whether to operate on an asymptomatic hernia is difficult, and their panel suggests that select asymptomatic patients may be offered repair on a case-by-case basis.
The concern with a “watch and wait” approach is that paraesophageal hernias tend to enlarge over time, and the risk of gastric volvulus increases with hernia size. On the other hand, surgery carries its own risks, especially in older adults who make up the largest share of patients.
What Surgery Involves
The standard approach is laparoscopic (minimally invasive) repair. The surgeon works through several small incisions to pull the stomach back into the abdomen, then narrows the widened opening in the diaphragm by stitching the muscular pillars (crura) closer together. Most surgeons also perform a fundoplication, wrapping the upper part of the stomach around the lower esophagus to reinforce the area and reduce reflux.
Whether to reinforce the repair with mesh remains a debated question. Recurrence rates with stitches alone range from 20% to 42%, while mesh-reinforced repairs bring that number below 10%. However, mesh carries its own risks: the body’s reaction to the material can cause scar tissue that makes swallowing difficult, and in rare cases, the mesh can erode into the esophagus. When mesh is used, biologic materials (derived from tissue rather than synthetic polymers) are chosen in the majority of cases to reduce these complications.
Recovery After Repair
After surgery, you’ll start with clear liquids once you’re fully awake and free of nausea. If those go down well, you’ll progress to a soft or pureed diet before leaving the hospital. Plan on staying on that soft diet for about two weeks. At your follow-up appointment, if swallowing feels normal, you’ll be guided through a gradual return to regular foods. If you’re still having some difficulty swallowing at two weeks, which is not unusual given the swelling from surgery, the soft diet may continue for up to six weeks.
The good news on the other side of recovery is encouraging. A study published in JAMA Surgery found that even among the 27% of patients whose hernias showed signs of recurrence on imaging at one year, those recurrences were often small and asymptomatic. Quality of life after repair was excellent in the long term regardless of what follow-up X-rays showed. In other words, a radiographic recurrence (something visible on a scan) does not necessarily mean a return of symptoms. Factors like BMI, lung disease, and specific surgical techniques like mesh use or stomach anchoring have not been clearly shown to predict who will and won’t have a recurrence, making it a somewhat unpredictable aspect of recovery that surgeons continue to study.