DIAPHRAGMATIC HERNIAS

Diaphragmatic hernia represents herniation of abdominal organs through natural

openings of diaphragm, its weak places or ruptures.

Etiology and pathogenesis

The cause of occurrence of congenital hernia is the disturbance of embryogenesis with
transformation in anomaly of diaphragm. The acquired diaphragmatic hernia more often arise
owing to age-dependent involution of diaphragm, its ptosis in the people with a mainly sedentary
mode of life, increase of intraperitoneal pressure, obesity, cough, overfeeding, constipation,
meteorism and pregnancy. The cause of sliding hernias can be draw of esophagus upward in
reflux esophagitis owing to intensive contraction of its longitudinal musculature.

1– norm, 2 – sliding hiatal hernia, 3 – paraesophageal hernia

Pathology
As well as any hernia, diaphragmatic has hernial ring, hernial sac and hernial content.
The tissues in the region of hilus, due to tension and pressure, result in atrophy and sclerosis.
necrosis, chronic inflammation, adhesions of the hernial content can develop.

Classification
There are such types of hernia:
1) congenital;
2) acquired;
3) posttraumatic;
4) true;
5) false.
А. Diaphragmatic hernia.
I. Sliding (axial) diaphragmatic hernia:
1) esophageal;
2) cardial;
3) cardiofundal.
ІІ. Diaphragmatic hernia of paraesophageal type:
1) fundal;
2) antral;
3) intestinal (small and large intestine);
4) combined intestinal-gastric hernias;
5) epiploic.
ІІІ. Huge diaphragmatic hernia:
1) subtotal gastric;
2) total gastric.
ІV. A short esophagus:
1) acquired short esophagus;
2) congenital short esophagus (thoracic stomach).
B. Parasternal hernias:
1) retrosternal;
2) retrocostosternal.
C. Lumbocostal diaphragmatic hernias.
D. Hernia of atypical localization.

Sliding (axial)

Paraesophageal
Esophageal hernias:

Esophageal

Cardiofundal

Mixed paraesophageal
 Paraesophageal fundal

Symptomatology and clinical course

The predominant manifestations resulting from sliding diaphragmatic hernia (about 90 %
of diaphragmatic hernias) are the signs of gastroesophageal reflux. It is characterized by the pain
behind breastbone or epigastric region. It more often appears in supine position after meal or
after intensive physical exertion.
Heartburn is the second according to the frequency sign and caused by the injury of
esophageal mucosa by gastric juice as a result in turn of gastroesophageal reflux.
Belching by air, as a rule, observed, which commonly results in pain relief and decrease
of arching feeling in epigastric region.
Regurgitation arises owing to gastroesophageal reflux, which reaches pharynx and oral
cavity. More often observed regurgitation by gastric acid or bitter liquid or food.
The sign of "lacing shoes" is expressed when the patient bends down after liquid food,
and the latter is partially poured out into the mouth. It is caused by incompetence of the lower
esophageal sphincter (gastroesophageal junction).
Nausea and vomiting are rare. The latter some patients cause by themselves to achieve
some relief.
Dysphagia is rarely observed. More often it is the outcome of complications of
diaphragmatic hernia (esophageal stricture, malignancy).
Roentgenological signs: 1) the sign of "bell"; 2) blunt His angle; 3) lack of air bubble of
the stomach.
 Sliding diaphragmatic hernia

The clinical manifestations of paraesophageal, retrosternal or lumbocostal hernias

basically depend on the character of organs, which the hernial sac contents, and their
compressing by hernial ring. Sometimes the clinical course even of major hernias is
asymptomatic, and they are occasionally found out during X-ray examinations. For the first time
the disease can manifest under the influence of physical exertion, trauma, pregnancy, labors etc.
 Paraesophageal hernia

Variants of clinical course and complications

The sliding hiatal hernia commonly has typical clinical course and rather rich
symptomatology, which enable to establish the diagnosis with a great degree of probability.
Nevertheless occasionally gastroesophageal reflux as the sequel of a sliding hiatal hernia can
result in misdiagnostics (stenocardia, acute cholelithiasis etc.).
The most often complications of sliding diaphragmatic hernia are gastric bleeding, peptic
stricture of esophagus and malignancy.
The causes of the bleeding can be erosion and ulcers of stomach, which result from
compression of the organ in esophageal hiatus. More often observed small bleeding, but at long-
stand recurrent course they result in chronic anemia. The profuse bleeding arise rarely. The
strangulation of a sliding diaphragmatic hernia never occurs.
Nevertheless for diaphragmatic hernias of other locations the most dangerous
complication is naturally strangulation. Such pathology manifests by the signs of s strangulation
intestinal obstruction. However the correct diagnosis frequently possible to establish only during
operation.

The diagnostic program

1. Anamnesis and physical findings.
2. X-radiography of chest and abdomen.
3. Esophagogastroscopy with biopsy and histological investigation.
4. Contrast X-radiography of esophagus and stomach in three positions: upward, supine
and upside-down position.
5. General blood and urine analyses.
6. Coagulogram.
 Sliding hernia

Paraesophageal hernia
 Mixed hernia

Differential diagnostics
Stenocardia. Diaphragmatic hernias frequently cause the pain, which character not only
the patient, but also doctor can identify as anginal. However in diaphragmatic hernia the pain
more often is vague, spread to the stomach region and depends on body position. The pain, as a
rule, arises in supine position and disappears, if the patient upward. More often it spreads to the
right and anginal vice versa to the left. In diaphragmatic hernia the ECG can manifest the
coronary failure, nevertheless standing up, owing to the stop of strangulation leads to
disappearance of these pathological sings. The pain caused by diaphragmatic hernia does not
relieve after nitroglycerin. In this case more effective and prompt is atropine.
Peptic ulcer. The pain in gastric and duodenal ulcer frequently localized in epigastric
region with irradiation in the left or right hypochondrium. Nevertheless, it is characterized by
periodicity, which caused by meal and disappears after the usage of soda.
Lung atelectasis, pleurisy, pneumonia are also should be differentiated with
diaphragmatic hernia. Thus it is always necessary to remember, that the extrapulmonary shadow
of supradiaphragmatic disposed hernia on a plain roentgenogram can resemble intrapulmonary.
For correct diagnosis it is possible to recommend polypositional X-radiography, contrast
roentgenography of esophagus and stomach.
Hypochromic anemia frequently associated due to repeated or permanent small
bleedings. They are caused by a regional destruction a gastric mucosa. In the females of senior
age if it is fail to explain genesis of the revealed anemia, it is necessary to think about the
opportunity of diaphragmatic hernia and carry out appropriate X-ray examination.

Tactics and choice of treatment

The medical tactics toward diaphragmatic hernias of different localization essentially
differs.
In case of sliding hiatal hernia the method of a choice is the conservative therapy:
1) the diet the same, as in peptic ulcer;
2) position of the patient during sleeping – with elevated upside, during exacerbation –
sedentary;
3) suppression of gastric secretion by administering of н2-blockers;
4) neutralization of gastric acid;
 5) intensifying of evacuation of the food from stomach;
6) avoidance of constipation;
7) anesthetics and sedative agents.
The indication for surgical treatment of sliding diaphragmatic hernia is the considerable
expression of clinical signs, diminish of patient's working capacity, fail of conservative
treatment, bleeding, peptic stricture, malignancy.
Surgical treatment. Upper median laparotomy is mainly used. Nevertheless some
surgeons prefer transthoracic accesses.
Stages of the operation:
1. Drawing of the stomach into abdominal vacuity by disjunction of adhesions in the
region of its cardial part, esophagus, excision of hernial sac.
2. The plastics of esophageal hiatus of diaphragm (cruroplasty). The most widespread
cruroplasty by Hill and narrowing of esophageal ring according to Garrington.
3. Elimination of valvular failure of esophagocardial junction. The purpose of
operation is to prevent gastroesophageal reflux by means of formation of His angle
and esophagocardial valve. Also Nissen fundoplication is applied.
4. Gastropexia – fixation of gastric wall to parietal peritoneum.
Another tactics is applied in the patients with paraesophageal, parasternal and
lumbocostal hernias. The method of choice is the surgery. Such tactics is explained by the hazard
of strangulation. The essence of the operation consists of drawing down of hernial content
(stomach, intestine, omentum) into abdominal cavity, removing of hernial sac and liquidation
(suturing) of hernial ring.

Steps of cruroplastic
 DIAPHRAGMATIC RELAXATION (DIAPHRAGMATIC EVENTRATION)
The term "diaphragmatic relaxation " was used for the first time in 1906 by Witting. It means a
relaxation of diaphragm, its high standing and displacement upward of abdominal organs.
The term ‘diaphragmatic eventration’ is used in common practice to describe a condition of
relaxation of the diaphragmatic dome. It may present at birth as a congenital condition due to a
defect of diaphragmatic development or in a later stage of life as an acquired condition
(‘acquired diaphragmatic paralysis’ or ‘acquired diaphragmatic elevation’).

Etiology and pathogenesis

The cause of the disease is the congenital or acquired decrease of diaphragmatic
resistance, which during elevation of intraperitoneal pressure results in its outpouching. The
great importance in the development of acquired relaxation belongs to the damage of
diaphragmatic nerve. The cause of the latter could be inflammatory processes in chest and
abdominal cavity, intoxication, poisoning, operations on chest organs and birth injury.

Pathology
In congenital form of a diaphragmatic relaxation revealed muscular aplasia, in acquired –
atrophy of muscular fibers.

Classification
1) Complete: left-side, right-side;
2) Incomplete: anterior, posterior, restricted (partial).

Symptomatology and clinical course

Minor manifestation or asymptomatic course characterizes diaphragmatic relaxation.
Therefrom, it is always necessary to thoroughly analyze the occurrence of multiple signs from
the organs of digestive, respiratory and cardiovascular system. The clinical symptomatology
basically depends on dysfunction of the diaphragm by itself and organs, which adjoin to it both
in chest, and in abdominal cavity. In left-side diaphragmatic relaxation the asymptomatic course
rarely occurs.
General symptomatology. The patients with diaphragmatic relaxation can feel a pain of
different character, localization and intensity. The pain syndrome frequently results from gastric
inflection or compression of vessels and nerves by filled stomach. Inflection of vascular bundles
of pancreas, lien, kidneys, mesentery of small and large intestines as a result of shift of
abdominal organs also contribute to the development of pain syndrome. Frequently patients
complain of general weakness and loss of weight.
Gastrointestinal symptomatology. Dysphagia almost always arises as a result of inflection
of abdominal part of esophagus. The heaviness after meal should be caused by atony of stomach
and its evacuation dysfunction. Ulceration and erosive gastritis, which occurs in some patients,
are the outcome of a regional ischemia from gastric inflection or torsion. Chronic constipation is
basically caused by disturbance of massage influence of the diaphragm on intestine. Meanwhile
heartburn, belching, nausea, vomiting and meteorism also observed.
A phrenocardiac Uden-Ramcheld's syndrome represents cardiopulmonary signs. It is
characterized by dyspnea, discomfort in the region of heart, anginal pain, extrasystole and ECG
changes (elongation of Р wave, РQ interval and complex QRS).
Respiratory disturbances result from dynamic dysfunction of the diaphragm. The high
standing of the diaphragm leads to compression of lung on the side of lesion and disturbed
ventilation of the lower part. It causes the diminishing of vital capacity of the lungs and
development of dyspnea.
Roentgenologically revealed the high standing of diaphragmatic dome (to ІІ-ІІІ
intercostal space), restriction of its excursion and reduce of the inferior pulmonary field.
Frequently observed the mediastinal shift to the opposite side. The contrast X-radiography of
esophagogastric junction can find out the inflection of abdominal part of esophagus. The X-ray
examination enables to establish the diagnosis with a high degree of reliability.

Diaphragmatic relaxation
 Variants of clinical course and complications
Asymptomatic course of diaphragmatic relaxation in the majority of patients has caused
interpretation of this pathology as "innocent disease". Nevertheless the shift and rotation of heart
can cause the heart failures, and the restriction of pulmonary excursion sometimes leads to
chronic pneumonia. The gastric inflection frequently may result in disturbance of the valvular
mechanism of esophagogastric junction and occurrence of reflux esophagitis.

The diagnostic program

1. Anamnesis and physical findings.
2. Plain chest X-radiography.
3. Esophagogastroduodenoscopy.
4. Roentgenoscopy of esophagus and gastrointestinal tract.
5. General blood and urine analyses.

Differential diagnostics
Diaphragmatic elevation is the secondary high standing, which can arise as a result of
ascites, pregnancy, expressed meteorism, peritonitis, tumours of abdomen, splenomegaly or
megacolon.
Pneumothorax, pyopneumothorax, pleurisy. Such misdiagnostics in the patients with
diaphragmatic relaxation frequently caused by chest pain, cough, dullness and tympanic sound
revealed at percussion, and weak breathing at auscultation. Chest X-radiography rather
contributes to exact diagnostics.
Diaphragmatic hernia. The differential diagnosis of diaphragmatic relaxation with this
pathology is the most difficult. Nevertheless it has the important practical value, because the
threat of strangulation of diaphragmatic hernia requires an active surgical tactics. During the
establishment of the diagnosis it is always necessary to remember, that clinical manifestation of
diaphragmatic hernia more expressed. However, the sharp inflection of abdominal organs in the
patients with diaphragmatic relaxation also can associate with severe pain, which resembles
strangulation. Thereafter, a reliably differentiation of these diseases is possible only after a goal-
oriented X-ray examination.
Cancer of esophagus and cardial part of stomach. A sharp gastric shift upward with
inflection of abdominal part of esophagus can lead to dysphagia, substernal pain, disturbance of
digestion, considerable loss of weight etc. For differential diagnostics applied a contrast X-ray
examination of esophagus and stomach.
In difficult for differential diagnostics cases a pneumoperitoneum with further X-ray
examination is performed. This method allows with a major degree of reliability to establish the
diagnosis of diaphragmatic relaxation.

Tactics and choice of treatment

In most cases the asymptomatic course of diaphragmatic relaxation requires no special
treatment.
Conservative therapy applied at presence of symptomatology:
1) avoidance of physical exertions, which increases intraperitoneal pressure;
2) diet – eating by small portions and exception of food, which form waste and gases;
3) therapeutic gymnastics for improving of intestinal function and decrease of the
patient's weight;
4) symptomatic therapy for regulation of cardiovascular and respiratory systems.
The indication for operation: gastric torsion or severe cardiorespiratory dysfunction. If
clinical manifestations are absent, the surgical treatment can be recommended only for women
with further pregnancy and labors, because these conditions cause a sharp increase of
intraperitoneal pressure with further shift of the diaphragm and abdominal organs.
Surgical treatment. By means of a lateral access in VІІ intercostal space a phrenoplasty is
performed, which consist of incision of diaphragm from costal edge to esophageal ring with
following diaphragmatic duplication.