Hernia (para-oesophageal)

A para-oesophageal or rolling hiatus hernia is a true herniation of the stomach into a peritoneal sac in the mediastinum.

• occurs when a defect in the phreno- oesophageal membrane allows a peritoneal sac to protrude alongside the oesophagus through the hiatus
• the defect usually lies at the left anterolateral portion of the oesophageal hiatus where the greater peritoneal sac reflects off the gastro-oesophageal junction
• less commonly, a hernia may occur posteriorly where the lesser peritoneal sac reflects off the junction.

Rolling hiatus herniae are less common (5-15% of all hiatus hernias) (1). The natural history is one of progressive enlargement. The entire stomach may herniate completely upwards into the sacs so that the pylorus comes to lie near the cardia, producing an inverted intra-thoracic stomach.

Frequently, the rolling hiatus hernia occurs in conjunction with a sliding type, producing a mixed hiatus hernia. Less often, other organs such as the colon, spleen, pancreas and small intestine may enter the peritoneal sac.

A para-oesophageal hernia may strangulate and cause sudden death. It accounts for about 10% of hiatus hernias and occurs in women four times as commonly as in men.

Reference:

• (1) Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ. 2014;349:g6154