A 70-year-old woman with a large type III (paraoesophageal) hiatus hernia found incidentally on CT is referred for opinion. She has mild heartburn controlled with a proton pump inhibitor but no anaemia, no dysphagia, and no chest symptoms. Why is operative repair generally advised even though her symptoms are mild?

• A Because proton pump inhibitors accelerate hernia enlargement
• B Because medical therapy cannot reduce acid secretion when the stomach is intrathoracic
• C Because all paraoesophageal hernias progress to Barrett's oesophagus within ten years
• D Because the whole stomach can migrate into the chest and undergo volvulus, incarceration, or strangulation, which carry significant mortality ✓

Explanation

In a true paraoesophageal hernia the gastro-oesophageal junction may remain fixed below the diaphragm while the fundus and body herniate alongside it. The herniated stomach can twist on itself, producing organoaxial or mesenteroaxial gastric volvulus, incarceration, strangulation, perforation, or bleeding from a Cameron ulcer. Because these emergencies carry appreciable mortality and cannot be predicted, repair is advised electively in fit patients even when symptoms are minimal. Proton pump inhibitors still work normally, and Barrett's oesophagus is a complication of sliding hernias and reflux, not of paraoesophageal herniation itself.

Reference: Sabiston Textbook of Surgery, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.