Unlikely a "large" paraesophageal hernia will be missed during an upper GI endoscopy in adults (done by an experienced endoscopist) - there are almost always taletell signs. Not sure about paediatric patients though.

Thanks Charalabopoulos for your expert opinion

But I would like ask you, what will be the endoscopic findings if the hernia was down when the endoscopy is performed? or it is not a possibility??

The best thing is to repair surgically this hernia as soon as possible

Dear Dr Sira,

One wouldn’t expect a Type III paraoesophageal hernia to spontaneously reduce on its own during OGD. I have never come across that! The tissues are too lax and the negative intrathoracic pressure always keeps most of the stomach in the chest.

Hope that helps

Dear Dr Charalabopoulos,

Thanks for your reply

But do you think that it could be different in young age specially that endoscopy was done while there was no any respiratory symptoms. Later on when the HH was discovered by imaging, respiratory symptoms was present and it was the leading cause for doing imaging studies!

Thanks for your kind discussion.

Thank you for sharing your experience. If the OGDS was to look for gastric abnormality, then one would have missed the paraoesophageal hernia. In my own experience, I will not do OGDS as a primary assessment for recurrent vomiting in a- 6- month old baby; I have experience of seeing short oesophagus whilst doing the OGDS in patients with paraoesophageal hernia. The ability to recognise that it is a short oesophagus is also not easy if one does have experience with OGDS in infants. All the best!

Thanks Dr Abdul Aziz

You are most welcome. Btw my last sentence should be "The ability to recognise that it is a short oesophagus is also not easy even if one does have experience with OGDS in infants"

Thank you very much Dr Abdul Aziz

Unlikely this anatomic disorder can be missed by a good upper GI endoscopy, unless gastric expansion can not be correctly reached (ex : poor sedation ...). I think that experienced endoscopist can not miss this pathology

Ideally, the endoscope should be turned upon itself into a U turn so that the esophageal hiatus is visualized and such hiatus hernias are not missed.

Thanks Dr Powdwal,

Of course we do routinely for every case otherwise endoscopy wouldn't be considered performed.

But it was a fact that upper endoscopy was free by the expert endoscopist. My question is; should paraesohageal hiatal hernia be persistently herniating through the hiatal opening or it sometimes reduces and sometimes herniated?!

Yes, A para-esophageal hernia will always be present being drawn into the chest by negative intrathoracic pressure. A sliding hernia may come and go.

Yes it could be happen

Barium swallow and endoscopy are the best methods for diagnosis of paraoesophageal hernia in symptomatic patients. Endoscopist is need to be experienced endoscopist.

Yes it could happen in huge large one

It can happen if the neck of the hernia is very small

In adults and children this is possible. More common with sliding hernias but Endoscopy (user interpretation, effects of gas insufflation, difficulty identifying the diaphragm in very large defects and intermittent reduction of the hernia ) can be challenging. If the CT shows a large hernia then this test defines the problem

Thank you Dr Davies for your expert answer