Paraesophageal hernia

Joye Varghese; Venkataraman Jayanthi

doi:10.1503/cmaj.060952

What's your call?

Figure. Radiograph with barium swallow from a 60-year-old emaciated man who presented with nonprogressive dysphagia of 8 months' duration.

Paraesophageal hernia occurs when a portion of the gastric fundus herniates through the diaphragm along the distal esophagus. Why such hernias form is unclear, but they are likely congenital in origin or secondary to a weakness or defect in the phrenoesophageal membrane, especially following surgery in the splenic bed. Paraesophageal hernias differ from sliding hiatus hernias in that they are less common and do not involve a displacement of the gastroesophageal junction.

In general, paraesophageal hernias are asymptomatic. However, patients may present with epigastric or substernal pain or fullness, nausea and dysphagia. Complications such as incarceration, gastric volvulus and perforation are rare but are the reasons why elective surgery is sometimes performed prophylactically.

In cases of paraesophageal hernia, radiography with barium swallow will show a portion of the gastric fundus herniating along the distal esophagus (Fig. 1). In our case, a delay in entry of barium into the herniated sac was not discernible during fluoroscopy. Demonstration of the gastric cardia below the diaphragm differentiates paraesophageal hernias from sliding hiatus hernias. On CT scans enhanced with contrast material, paraesophageal hernias can be distinguished from other thoracic lesions (e.g., lower esophageal duplications cysts, lower thoracic aortic aneurysms and neuroenteric cysts) by their appearance as a mediastinal mass filled with barium and air located behind the heart and along the esophagus (Fig. 2). In some cases patients may have both a sliding hiatus hernia and a paraesophageal hernia, with radiographic features of both.

Fig. 1: Herniation of the gastric fundus (arrow) into the thoracic cavity and compression of the distal esophagus.

Fig. 2: CT scan of thorax showing herniation of stomach into the thoracic cavity (arrow). L = liver, H = heart, E = esophagus, S = stomach, A = aorta.

Joye Varghese Venkataraman Jayanthi Department of Medical Gastroenterology Stanley Medical College Hospital Chennai, India