Diaphragmatic hernia
The content of the article:
- Causes and risk factors
- Form and degree of the disease
- Diaphragmatic hernia symptoms
- Diagnostics
- Diaphragmatic hernia treatment
- Potential consequences and complications
- Forecast
- Prevention
Diaphragmatic hernia (hiatal hernia, paraesophageal hernia) - displacement of the anatomical structures of the abdominal cavity (bowel loops, cardiac stomach, abdominal part of the esophagus) into the chest through the opening in the diaphragm. The disease is widespread, but in about half of cases it remains undiagnosed, since it is asymptomatic.
Diaphragmatic hernia in children is rare, the incidence rate increases with age. So, up to 40 years old, diaphragmatic hernia is observed in about 9% of the population, and after 70 years - in 69%. Women get sick more often than men.
Source: med-explorer.ru
Causes and risk factors
Diaphragmatic hernias are classified as congenital or acquired. In newborns, diaphragmatic hernias are an intrauterine malformation, consisting in a decrease in the length of the esophagus. The disease requires surgical correction, which is carried out in the first months of a baby's life.
The pathological mechanism of the formation of a diaphragmatic hernia is based on the processes of atrophy of connective tissue and its loss of elasticity, which leads to weakness of the ligamentous apparatus that supports the esophagus in the opening of the diaphragm. As a result, the diaphragmatic ring increases in diameter and turns into a hernial gate, through which internal organs protrude into the chest cavity, which are normally located below the level of the diaphragm.
With age, the body undergoes natural aging processes, accompanied by degenerative changes in the connective tissue, which is the reason for most diaphragmatic hernias.
The disease often affects those who suffer from connective tissue diseases (intestinal diverticulosis, hemorrhoids, varicose veins, flat feet, Marfan syndrome), as well as detrained asthenized persons. Therefore, it is often combined with other types of hernias (umbilical, white line of the abdomen, inguinal, femoral).
Factors that increase the risk of diaphragmatic hernia formation are:
- a critical sudden or constant increase in intra-abdominal pressure (blunt abdominal trauma, lifting a heavy load, II and III degrees of obesity, weightlifting and work requiring significant physical effort; ascites, flatulence, indomitable vomiting, chronic constipation, repeated childbirth, prolonged cough);
- chronic impairment of gastrointestinal motility, observed against the background of a number of diseases (calculous cholecystitis, chronic pancreatitis, chronic gastroduodenitis, gastric ulcer and duodenal ulcer);
- cicatricial-inflammatory processes leading to a longitudinal shortening of the esophagus and resulting from thermal or chemical burns of the esophagus, peptic esophageal ulcer, reflux esophagitis, Zollinger-Ellison syndrome.
Form and degree of the disease
In accordance with the features of the anatomical structure, diaphragmatic hernias are divided into the following types:
- sliding (axial, axial) - the abdominal part of the esophagus, the cardia and the fundus of the stomach freely penetrate into the chest cavity through the expanded diaphragmatic ring. When the position of the body changes, the organs come back and take the correct anatomical position. Sliding diaphragmatic hernias in clinical practice are most often observed and, in turn, are subdivided, depending on the displaced area, into subtotal and total gastric, cardiofundal, cardiac;
- paraesophageal - their sign is displacement into the thoracic cavity of the stomach and its location is paraesophageal, that is, next to the thoracic part of the esophagus, and the distal part of the esophagus remains in the subphrenic space. Paroesophageal hernias are divided into fundic and antral;
- mixed - combine the signs of paraesophageal and sliding diaphragmatic hernias;
- a short esophagus is a congenital developmental anomaly, leading to a "pull-up" of the stomach and its placement in the chest cavity.
Depending on the data of X-ray examination of the gastrointestinal tract with contrast, three degrees of diaphragmatic hernias are distinguished:
- The abdominal part of the esophagus protrudes into the chest cavity, the stomach is adjacent to the diaphragm.
- The abdominal part of the esophagus is located in the chest cavity, the stomach is located in the area of the enlarged esophageal ring of the diaphragm.
- Above the level of the diaphragm are the abdominal part of the esophagus and the stomach (cardia, fundus, body).
Source: myshared.ru
Diaphragmatic hernia symptoms
In every second case, there are no symptoms of diaphragmatic hernia in patients, and it is a diagnostic finding. In other patients, the disease is manifested, first of all, by pain syndrome. The typical site of pain localization is the epigastric region. The pain can radiate to the back, interscapular region. Often it becomes shingles, with the result that the clinical picture of the disease resembles pancreatitis. In some patients, pain is localized behind the sternum, resembling myocardial infarction, angina pectoris (this pain is called non-coronary cardialgia).
In about 35% of patients, a symptom of a diaphragmatic hernia is arrhythmia such as paroxysmal tachycardia or extrasystole. Often, cardiologists have been unsuccessfully treating such patients for a long time.
The characteristic features of the pain syndrome that occurs against the background of a diaphragmatic hernia are:
- the onset of an attack after physical exertion, eating, coughing, with severe flatulence, in the supine position;
- disappearance or weakening after belching, drinking, changing body position, deep breath, vomiting;
- gain when performing a forward bend.
When a diaphragmatic hernia is pinched, the patient's condition quickly and significantly worsens. They have:
- cramping intense pain, localized behind the sternum and radiating to the back;
- severe nausea;
- repeated vomiting mixed with blood;
- increasing shortness of breath;
- cyanosis;
- tachycardia;
- a sharp decrease in blood pressure.
Over time, a diaphragmatic hernia leads to the formation of gastroesophageal reflux disease, accompanied by a number of dyspeptic symptoms (belching with air, bile or stomach contents, a feeling of bitterness in the mouth, regurgitation of recently eaten food, regurgitation when lying down).
Another pathognomonic sign of a diaphragmatic hernia is a violation of the passage of food through the esophagus, that is, dysphagia. Most often, dysphagia is not spontaneous, but is provoked by:
- psycho-traumatic factors;
- hasty food;
- too hot or cold food;
- taking liquid or semi-liquid food.
Also, as manifestations of a diaphragmatic hernia can be:
- hoarseness of the voice;
- burning sensation and / or pain in the tongue;
- hiccups;
- heartburn.
Diagnostics
In most cases, a diaphragmatic hernia is first detected during fibrogastroduodenoscopy or X-ray examination of the chest, esophagus and stomach.
Radiographic signs of a diaphragmatic hernia are:
- delayed suspension of barium in the hernia;
- expansion of the esophageal opening of the diaphragm;
- absence in the subphrenic space of the shadow of the esophagus;
- the location of the cardia over the diaphragm.
During an endoscopic examination with a diaphragmatic hernia, symptoms of esophagitis and gastritis, the presence of erosions and ulcers on the mucous membrane, the location of the esophageal-gastric line above the dome of the diaphragm are revealed. To exclude a neoplastic process, a biopsy of ulcers is performed, followed by a histological examination of the resulting biopsy.
With a diaphragmatic hernia, bleeding from erosions and ulcers of the mucous membrane of the esophagus and stomach may occur. In order to identify possible latent bleeding, patients are prescribed a study of feces for occult blood.
Other methods of instrumental diagnostics of diaphragmatic hernia are:
- esophageal manometry - allows you to assess the functional state of the pharyngeal-esophageal and cardiac sphincters, the amplitude, duration and nature (peristaltic or spastic) of contractions of the walls of the esophagus;
- intragastric and intraesophageal pH-metry;
- impedance measurement;
- gastrocardiomonitoring.
Source: medweb.ru
Diaphragmatic hernia treatment
Conservative therapy for diaphragmatic hernias is aimed at eliminating the signs of gastroesophageal reflux.
The therapy regimen includes:
- antacids;
- H 2 -histamine receptor blockers;
- proton pump inhibitors.
In addition to drug therapy, patients with diaphragmatic hernia are recommended:
- give up excessive physical exertion;
- follow a diet (table number 1 according to Pevzner);
- last meal a day no later than three hours before bedtime;
- sleep in a bed with a raised head end.
The indications for surgical treatment of diaphragmatic hernias are:
- ineffectiveness of the ongoing conservative therapy of the disease;
- the appearance of dysplastic changes in the mucous membrane of the esophagus.
During the operation, the esophageal-phrenic ligament is strengthened, the enlarged esophageal ring is sutured (plastic hernial orifice). If necessary, additionally perform gastropexy (fixation of the stomach).
With cicatricial narrowing of the esophagus, it is bougienated, and if this procedure is ineffective, there are indications for esophageal plastic surgery.
Source: opischevode.ru
Potential consequences and complications
In the supine position, patients with diaphragmatic hernias often experience regurgitation, in which acidic gastric contents can enter the airways, leading to the development of tracheobronchitis, aspiration pneumonia, and bronchial asthma.
Another complication of diaphragmatic hernias is internal bleeding from peptic ulcers of the esophagus, erosions and ulcers of the gastric mucosa. Long-term blood loss leads to the development of iron deficiency anemia.
Forecast
With timely and active treatment, the prognosis is favorable. After surgery, the risk of recurrence is minimal.
In the absence of treatment for diaphragmatic hernia, with a prolonged course of esophagitis, the risk of developing a malignant tumor of the esophagus increases several times.
Prevention
Prevention of diaphragmatic hernia formation includes the following measures:
- normalization of body weight;
- exclusion of excessive physical exertion;
- constipation therapy;
- strengthening the abdominal muscles (physical therapy, swimming, yoga).
All patients with diagnosed diaphragmatic hernia should be monitored by a gastroenterologist and receive the necessary therapy in a timely manner, which significantly reduces the risk of developing complications of the disease.
YouTube video related to the article:
Elena Minkina Doctor anesthesiologist-resuscitator About the author
Education: graduated from the Tashkent State Medical Institute, specializing in general medicine in 1991. Repeatedly passed refresher courses.
Work experience: anesthesiologist-resuscitator of the city maternity complex, resuscitator of the hemodialysis department.
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
