Clinical features of type III (mixed) paraesophageal hernia

The clinical presentation of patients with a paraesophageal hernia is poorly understood. The aim of this study was to evaluate the progression of symptoms in patients with type III paraesophageal hernia.

We evaluated 25 patients (mean age 66 yr) with a type III paraesophageal hernia, who then had laparoscopic surgical repair. The patients characterized their symptoms as 1) chronic or 2) prompting evaluation (progressive or new). We defined postprandial distress as chest or epigastric pain, shortness of breath, or nausea or vomiting during or shortly after meals.

We identified three distinct types of chronic symptoms: heartburn only (36%), heartburn and postprandial distress (32%), and postprandial distress only (32%). Twenty-three patients (92%) reported postprandial distress as the symptom prompting evaluation compared with only 10 patients (40%) reporting heartburn. Eight patients (32%) never had heartburn. Postprandial distress was their only symptom. Laparoscopic repair of the paraesophageal hernia resolved postprandial distress in 74% and improved symptoms in the remaining 26% of patients (mean follow-up 12 months).

Post-prandial distress is the most prominent symptom in patients with a type III paraesophageal hernia. Most patients had chronic symptoms of a sliding hiatal hernia but later featured more pronounced postprandial distress. However, one-third of the patients never experienced significant heartburn. A type III paraesophageal hernia should be suspected in patients, with or without heartburn, who develop new or progressive symptoms of postprandial distress.