Paraesophageal Hernia and Intrathoracic Diverticulitis

J Am Board Fam Med. 2000;13(2) 

In This Article


Hiatal hernias occur as three major types: type I, the classic sliding hiatal hernia in which the esophagogastric junction is located above the diaphragm; type II, in which the esophagogastric junction remains below the diaphragm but the fundus of the stomach is prolapsed above the diaphragm; and type III, a mixed type in which both the esophagogastric junction and some or all the stomach are above the diaphragm, but in which the esophagogastric junction remains more caudal than the fundus.[2,3,4] Most paraesophageal hernias are type III; type II is relatively uncommon.

The hernia is due to attenuation of the anterior and lateral components of the phrenicoesophageal fascial complex. The resulting weakness in the muscle fibers creates mobility and instability within the hiatus, which allows for herniation into the mediastinum of the stomach, the transverse colon, and on rare occasions the entire bowel or other intraabdominal organs, such as the spleen.

Listerud and Harkins[5] described 11 muscle variations in the formation of an esophageal hiatus. In more than 90% of the reported cases, the hiatus is produced from the right crus. Documentation of rarer cases of paraesophageal hiatal hernias in which the transverse colon might be involved include a report of a patient who had a paraesophageal hernia in which herniation of the splenic flexure led to colonic obstruction.[6] Another report described a rarer event in which a hernia through the aortic hiatus allowed passage of first the stomach and then the colon through the diaphragm.[7]

Paraesophageal hiatal hernias can occur, though very seldom, as congenital problems diagnosed in infancy.[8] They are found predominately as acquired problems in the elderly. Patients might complain of reflux, epigastric pressure or pain, postprandial vomiting of food, postprandial dyspnea, anemia, or symptoms of intermittent volvulus.[9] When the symptoms and signs of paraesophageal hernia include sudden onset of abdominal pain and vomiting, they are likely a result of strangulation of herniated stomach or bowel, which is a medical emergency.

Although paraesophageal hernias account for only 5% of all hiatal hernias, they are dangerous because symptoms can be nonspecific, leading to delays in diagnosis and resultant morbidity or mortality. Paraesophageal hernia should be suspected in elderly patients who have symptoms ranging from heartburn and vague abdominal discomfort to vomiting and severe pain. These patients might have few or no localizing abdominal findings on physical examination, but they have evidence of hiatal hernia on chest radiographs. Wo et al[10] recommended that patients with heartburn, plus post-prandial distress (pain in the epigastrium or chest, dyspnea, nausea or vomiting during or after eating), be suspected of having paraesophageal hernia, especially type III, rather than simply the more common sliding hiatal hernia (type I).

The finding of a stomach-type air-fluid level or large-bowel gas pattern within the mediastinum should further raise suspicion of a paraesophageal rather than sliding hiatal hernia. The differential diagnosis for mediastinal masses occurring with similar appearance includes pericardial effusion or cyst, bronchogenic cyst, or esophageal diverticulum.[11] Upper gastrointestinal endoscopy can establish the diagnosis, but a type III hernia is often missed by endoscopy. Barium esophagogram might be necessary to confirm a type III hernia.[10]

Most authors recommend surgical repair of paraesophageal hernias at the time of diagnosis because of the risk of strangulation and its high mortality rate.[12] Older case series included large proportions of emergency procedures. For example, of 29 patients with paraesophageal hernias reported by Hill,[13] 10 required emergency surgical repair of the strangulation and obstruction, and 2 of those cases resulted in death. More recent series have described much better elective surgical outcomes, particularly those in which repair is accomplished laparoscopically.[9,14,15,16] Successful emergency laparoscopic repair has also been described.[17] In some instances, symptoms have been present for many years, and the patient might be unwilling to undergo surgery to correct the condition. Some have suggested that the risk of emergency complications of hiatal hernias might be lower than generally believed, given the occasional patient in whom bowel is only incidentally identified in the thorax.[18]

In the case reported here, nonsurgical management was considered to be appropriate because of the advanced age of the patient, the patient's early dementia, and family refusal. The patient did not develop symptoms or signs of bowel obstruction. His initial abdominal pain was believed to represent referred pain from intrathoracic diverticulitis that improved with antibiotic treatment.