Yes. A sliding hiatal hernia can sometimes enlarge or develop a paraesophageal component, creating a mixed hernia. In this pattern, the place where the esophagus joins the stomach may sit above the diaphragm while another part of the stomach pushes up beside the esophagus. This does not happen to everyone, and a person’s chance cannot be predicted from symptoms or one scan alone.
How are sliding and paraesophageal hiatal hernias different?
A hiatal hernia occurs when part of the stomach moves through an opening in the diaphragm, the muscle that separates the chest from the abdomen. The two main types differ in which parts of the stomach move upward and where the junction between the esophagus and stomach sits.
According to the Cleveland Clinic, a sliding hiatal hernia is the most common type. The junction between the esophagus and stomach, along with part of the stomach, moves above the diaphragm. A paraesophageal hernia develops when part of the stomach pushes upward beside the esophagus, while the junction may remain in its usual position below the diaphragm.
Doctors also recognize a mixed hiatal hernia, known as a type III hernia. It has features of both types: the junction between the esophagus and stomach moves above the diaphragm, and another portion of the stomach pushes upward beside the esophagus. This mixed pattern is particularly relevant when discussing whether a sliding hernia can become paraesophageal.
Can a sliding hiatal hernia change into a paraesophageal hernia over time?
Yes, this change has been documented. A sliding hiatal hernia may remain stable, increase in size, or develop a paraesophageal component over time. However, progression is not inevitable, and the available research does not provide a reliable prediction for every person with a sliding hernia.
A study published in Annals of Surgery, available through PubMed, examined imaging records from 89 people who had at least two upper gastrointestinal studies performed at least five years apart. Among the 55 people whose initial study showed a sliding hiatal hernia, 14 were found to have a paraesophageal hernia on follow-up imaging. The median interval between studies in this group was 84 months.
Although that finding shows that a change is possible, it should not be interpreted as meaning that one in four people with a sliding hiatal hernia will develop a paraesophageal hernia. The study included a small, selected group of people who had repeat imaging over several years. Its results do not establish the likelihood of progression in the general population.
Why might the type of hiatal hernia change?
The opening in the diaphragm through which the esophagus passes is called the esophageal hiatus. Supporting tissues help keep the esophagus and stomach in their normal positions. When these tissues stretch and the opening widens, more of the stomach may be able to move into the chest.
The Cleveland Clinic explains that hiatal hernias can develop gradually over many years and that strain can contribute to widening of the opening. However, the exact process behind changes from a sliding hernia to a paraesophageal or mixed hernia is not fully understood.
Age-related tissue changes and the forces acting on the diaphragm may contribute to the development or enlargement of a hiatal hernia. These factors do not mean that an existing sliding hernia will necessarily progress. Some hernias remain stable, while others change in size or anatomy.
Does a paraesophageal component cause different symptoms?
Not always. Sliding hiatal hernias are often associated with acid reflux, which may cause heartburn, regurgitation, or discomfort after eating. Some people have no symptoms at all. A paraesophageal or mixed hernia can also cause no noticeable symptoms, but a larger hernia may produce symptoms related to the position of the stomach or pressure within the chest or upper abdomen.
Possible experiences include:
- Heartburn or food and stomach acid flowing back toward the throat.
- Feeling full soon after eating or experiencing upper abdominal discomfort.
- Difficulty swallowing.
- Chest discomfort or upper abdominal pain.
- Shortness of breath in some people with larger hernias.
These symptoms do not reliably distinguish a sliding hernia from a paraesophageal or mixed hernia. Their significance depends on the person's history, the pattern of symptoms, examination findings, and imaging results.
What complications can occur if a hernia becomes paraesophageal?
One important concern is that part of the stomach can become trapped in the opening of the diaphragm. In some cases, the stomach may twist or become compressed, potentially blocking the passage of food and cutting off its blood supply. These complications are uncommon, but they can be dangerous and may require emergency surgery.
The University of Chicago Medicine identifies sharp chest pain, vomiting, fever, and bloody stools as possible warning signs of a stomach that has twisted and lost its normal blood supply.
Seek emergency medical care if sudden, severe chest or upper abdominal pain develops, particularly with persistent vomiting, fever, or signs of gastrointestinal bleeding. New chest pain should not automatically be attributed to a known hiatal hernia, because it can also signal other serious conditions.
How do doctors determine whether a sliding hernia has become paraesophageal?
Symptoms alone cannot show whether the anatomy of a hiatal hernia has changed. A healthcare professional may recommend imaging or other investigations based on previous findings, current symptoms, and medical history.
According to the Merck Manual Professional Edition, a barium swallow, also called an upper gastrointestinal contrast study, is an important test for identifying a hiatal hernia. The person drinks a contrast liquid while X-ray images show the position of the esophagus and stomach relative to the diaphragm.
Other tests may include:
- Upper endoscopy: A flexible tube with a camera allows a clinician to examine the esophagus and stomach and look for inflammation or other problems.
- CT scan: Cross-sectional images may help show the position and extent of a hernia, particularly when a more complicated anatomical change is suspected.
- Esophageal manometry: This test measures pressure and muscle function in the esophagus and may be used when additional information is needed.
The Johns Hopkins Medicine resource on hiatal hernias describes the use of barium X-rays, CT imaging, and endoscopy to evaluate the location of the stomach and associated changes. The appropriate combination of tests depends on the clinical question and the information already available.
When earlier imaging is available, a clinician may compare it with newer results to determine whether the hernia has increased in size or developed a different anatomical pattern. A change in the wording of an imaging report should be interpreted alongside the actual findings and the reason for the examination.
Does a paraesophageal change mean surgery is necessary?
No. The discovery of a paraesophageal component does not automatically mean that surgery is required immediately. The decision depends on the type and size of the hernia, related symptoms, complications, overall health, and the potential benefits and risks of treatment.
Some people with uncomplicated sliding hernias need only management of associated reflux symptoms. A symptomatic paraesophageal or mixed hernia may warrant assessment by a surgeon experienced in esophageal and hiatal hernia conditions. Surgery may be recommended when symptoms or complications justify repair, while the approach to an asymptomatic hernia requires an individualized discussion.
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) clinical guidelines describe areas of uncertainty in decisions about surgery for asymptomatic hiatal hernias. They support careful decision-making based on the available evidence and the circumstances of the individual patient rather than treating every hernia in the same way.
When should you arrange a medical review?
Arrange an appointment with a healthcare professional if reflux symptoms persist despite usual treatment, swallowing becomes difficult, eating causes recurring discomfort, or existing symptoms become more frequent or disruptive. Review a new imaging finding with the clinician who ordered the test, especially when a report describes a larger, mixed, or paraesophageal hernia.
Knowing whether a hernia is sliding, paraesophageal, or mixed helps clinicians assess potential complications and decide whether monitoring, symptom management, or a surgical consultation is appropriate. The most useful next step is to understand the actual anatomy shown on imaging and how it relates to the person's symptoms and health history.