A paraesophageal hernia happens when part of your stomach pushes through the diaphragm into your chest, next to your esophagus. This is different from the more common sliding hiatal hernia. In a paraesophageal hernia, the stomach moves up beside the esophagus rather than through it, which can be more dangerous because it can become trapped or lose its blood supply.
What Causes A Paraesophageal Hernia
The diaphragm is a large dome-shaped muscle that separates your chest from your abdomen. Your esophagus passes through a small opening in the diaphragm called the hiatus. Normally, this opening fits snugly around the esophagus and keeps your stomach in place below it.
A paraesophageal hernia develops when this opening becomes too loose or too wide. When that happens, the stomach can slide upward through the gap and rest alongside the esophagus. Over time, the stomach may roll or rotate as it moves into the chest, which is why some doctors call it a “rolling” hiatal hernia.
The exact cause is not always clear. But a combination of weakness in the diaphragm and increased pressure in the abdomen is the most common explanation. Anything that pushes the stomach upward can contribute, and some people are simply born with a larger hiatus than others.
Who Gets Paraesophageal Hernias
Age is one of the strongest risk factors. The tissues of the diaphragm naturally weaken over time, and the opening around the esophagus can stretch. Most paraesophageal hernias are diagnosed in people over 60, though they can appear earlier.
Women are affected more often than men. Researchers are not entirely sure why, but pregnancy may play a role. The growing uterus increases abdominal pressure, and repeated pregnancies may stretch the diaphragm and weaken the hiatus over many years.
Obesity is another significant factor. Excess weight around the abdomen pushes the stomach upward and puts constant strain on the diaphragm opening. Some studies suggest that the rising rates of obesity have contributed to more hiatal hernias being diagnosed in recent decades.
Other things that increase abdominal pressure may also contribute. These include chronic constipation, frequent vomiting, heavy lifting, and coughing that lasts a long time. Any of these can push the stomach against a weakened diaphragm and encourage a hernia to form.
How It Differs From A Sliding Hiatal Hernia
Most hiatal hernias are the sliding type. In a sliding hernia, the junction where the esophagus meets the stomach moves up through the hiatus and slides back down. This type is very common and often causes no symptoms at all.
A paraesophageal hernia is different. The junction between the esophagus and stomach usually stays in place. Instead, the fundus — the upper part of the stomach — rolls up through the hiatus and sits next to the esophagus. This is why it is sometimes called a paraesophageal or rolling hernia.
The distinction matters because of the risks. A sliding hernia rarely causes emergency problems. A paraesophageal hernia can. The stomach can become trapped in the chest, a condition called incarceration. If the blood supply to the trapped stomach is cut off, it becomes a strangulated hernia. This is a surgical emergency.
Symptoms You Should Not Ignore
Many people with a paraesophageal hernia have no symptoms. The hernia is found incidentally during an imaging test for an unrelated problem. When symptoms do occur, they are often mild at first and can include heartburn, chest pain, and trouble swallowing.
Some people notice they feel full quickly when eating. Others experience shortness of breath because the stomach pressing into the chest leaves less room for the lungs to expand. Belching and a feeling that food gets stuck behind the breastbone are also common.
Certain symptoms require immediate medical attention. Severe chest pain, inability to swallow liquids, vomiting, and signs of bleeding such as black stools or vomiting blood can all indicate a strangulated hernia. If you have these symptoms, go to an emergency room without delay.
It is important to note that chest pain from a hernia can feel like a heart attack. If you have chest pain and are not sure of the cause, seek emergency care. The consequences of ignoring a heart attack are far worse than a false alarm.
How Doctors Diagnose It
A paraesophageal hernia is usually confirmed with imaging. A barium swallow test involves drinking a chalky liquid that coats the esophagus and stomach, making them visible on X-rays. This test shows whether the stomach has moved into the chest.
Endoscopy is another common tool. A thin tube with a camera is passed through the mouth into the esophagus and stomach. This allows the doctor to see the hernia directly and check for damage to the lining of the esophagus.
CT scans are sometimes used, especially in emergency situations. They provide detailed images that can show whether the stomach is twisted or whether blood flow appears compromised. In a true emergency, a CT scan may be done before any other test.
When Surgery Is Needed
This is where medical advice has changed in recent years. For a long time, doctors recommended surgery for nearly all paraesophageal hernias, even when patients had no symptoms. The reasoning was that the risk of strangulation was too high to wait.
Current evidence suggests a more careful approach. Research now indicates that the risk of strangulation in an asymptomatic paraesophageal hernia is lower than doctors once believed. Many experts now recommend watchful waiting for people who have no symptoms or only mild symptoms that are well controlled.
Surgery is clearly recommended when symptoms are present and bothersome. It is also recommended if the hernia causes complications such as bleeding, obstruction, or signs that the stomach is losing its blood supply. Elective surgery is safer than emergency surgery, so operating before a crisis develops is generally preferred.
The most common operation is a laparoscopic hernia repair. The surgeon moves the stomach back into the abdomen, closes the opening in the diaphragm, and sometimes wraps part of the stomach around the esophagus to reinforce the area. Recovery from laparoscopic surgery is typically faster than from open surgery, but every case is different.
What Happens Without Surgery
If you and your doctor decide to monitor the hernia rather than operate, you will need follow-up. That usually means periodic imaging to check whether the hernia has grown or changed. Symptom changes should be reported promptly.
Lifestyle measures can help manage symptoms. Eating smaller meals reduces pressure on the stomach. Avoiding foods that trigger heartburn — such as spicy foods, caffeine, and alcohol — can help. Staying upright for a few hours after eating allows gravity to keep the stomach contents down.
Weight loss can reduce abdominal pressure and may ease symptoms. If you are overweight, losing even a modest amount of weight can make a meaningful difference. Quitting smoking is also worthwhile because coughing from smoking increases abdominal pressure.
These measures do not fix the hernia. They only manage symptoms. The hernia itself will not heal on its own. If symptoms worsen or complications develop, surgery may become necessary.
Frequently Asked Questions
Can a paraesophageal hernia go away on its own?
No. A paraesophageal hernia is a structural problem that does not heal without surgery. The opening in the diaphragm does not close back up on its own.
Is a paraesophageal hernia an emergency?
Not always, but it can become one. If the stomach becomes trapped or loses its blood supply, that is a surgical emergency requiring immediate care.
What is the success rate of paraesophageal hernia surgery?
Surgery is effective for most people, with good long-term results in the majority of cases. However, hernias can recur, and some people continue to have symptoms after surgery.
Can you live with a paraesophageal hernia without surgery?
Yes, many people live with a paraesophageal hernia for years without serious problems. If you have no symptoms or mild symptoms, your doctor may recommend monitoring rather than surgery.
