From the Guidelines
The best diagnostic test for paraesophageal hernia is barium swallow (barium esophagram). This imaging study provides excellent visualization of the anatomical relationship between the stomach and esophagus, clearly demonstrating herniation of the stomach into the chest cavity. Barium swallow is particularly valuable because it shows the dynamic movement of the gastroesophageal junction and stomach during swallowing, allowing assessment of both the anatomical defect and its functional implications. While CT scans can identify paraesophageal hernias, they are generally considered second-line tests as they don't provide the same dynamic functional information. Barium studies are also advantageous because they are less expensive, involve less radiation exposure than CT, and can better characterize the type and size of the hernia, which is crucial for treatment planning. For these reasons, barium swallow remains the preferred initial diagnostic test for suspected paraesophageal hernias, as supported by the American College of Surgeons and reflected in the Esophageal Diagnostic Advisory Panel Consensus 1.
Some key points to consider when evaluating paraesophageal hernias include:
- The ability of barium swallow to differentiate between sliding hiatal hernias and paraesophageal hernias, which is important for determining the surgical approach 1
- The value of barium studies in evaluating the presence of associated pathology, such as oesophageal diverticulum or hiatus hernia 2
- The importance of characterizing the type and size of the hernia, which is crucial for treatment planning 2, 1
In contrast, CT scans, while useful for identifying diaphragmatic hernias, have a sensitivity and specificity of 14–82% and 87%, respectively, and may miss small tears or intermittent herniation 3. Therefore, barium swallow is the recommended initial diagnostic test for suspected paraesophageal hernias, due to its ability to provide dynamic functional information and characterize the hernia, which is essential for treatment planning.
From the Research
Diagnostic Options for Paraesophageal Hernia
- CT scan: Computed tomography (CT) can clearly demonstrate a paraesophageal hernia through a widened esophageal hiatus, often as an incidental finding, and accurately documents the size, contents, and orientation of the herniated stomach within the lower thoracic cavity 4.
- Barium swallow: Barium swallow studies can be used to evaluate the anatomy of the hernia and to assess for any complications such as gastric volvulus 5, 6.
- Upper endoscopy: Upper endoscopy can be used to evaluate the mucosa of the esophagus and stomach, and to assess for any complications such as esophagitis or gastritis 7.
Comparison of Diagnostic Options
- Both CT scan and barium swallow can be used to diagnose paraesophageal hernia, but CT scan may be more accurate in documenting the size and contents of the hernia 4.
- Barium swallow may be more useful in evaluating the anatomy of the hernia and assessing for complications such as gastric volvulus 5, 6.
- Upper endoscopy can be used to evaluate the mucosa of the esophagus and stomach, but may not be as useful in diagnosing paraesophageal hernia as CT scan or barium swallow 7.
Recommendations
- Patients with paraesophageal hernia should undergo a history and physical examination, upper endoscopy, and obtain radiographic evaluation of the PEH (e.g., barium esophagram, computed tomography scan) 7.
- Further testing should be directed by patient symptoms, especially in the case of discordance between symptoms and imaging findings 7.