Diaphragmatic hernia

Hiatal hernia (diaphragmatic hernia, diaphragmatocele) is a chronic relapsing disease of digestive system, associated with shift of hiatal into chest cavity (posterior mediastinum) of abdominal esophagus, cardia, upper part of stomach, and sometimes of bowel loops (T.G. Masevich, 1995).

Hiatal hernia is protrusion of stomach through esophageal opening. Most of hernias are asymptomatic, but progression of acid reflux can cause symptoms of gastro esophageal  reflux disease (GERD). Diagnosis is made with sip of barium fluoroscopy. Treatment of diaphragmatic hernia is symptomatic if there are signs of GERD.

As you know, esophagus passes through esophageal opening, before getting into cardiac section of stomach. Esophageal opening and esophagus and connected with very thin connective tissue membrane which hermetically separates abdominal cavity from chest. Pressure in abdominal cavity is higher than in chest, so if there are certain additional conditions stretching of membrane occurs, and abdominal part of esophagus with portion of gastric cardia may move into chest cavity, forming diaphragmatic hernia.

Hiatal hernia (diaphragmatic hernia, diaphragmatocele) is very common disease. It occurs in 0.5 % of adult population, and 50% of patients it does not provide any clinical signs and, consequently, cannot be diagnosed.

Causes of diaphragmatic hernia

Three groups of factors play decisive role in development of hiatal hernia (diaphragmatic hernia):

1. weakness of connective tissue structures, strengthening esophagus in opening of diaphragm;
2. increased intra-abdominal pressure;
3. traction of esophageal up  at dyskinesia of digestive system and diseases of esophagus.

Weakness of connective tissue structures, strengthening esophagus in opening of diaphragm

Weakness of ligamentous apparatus and fabric hiatal develops with increasing age of person in connection with involutive processes, so hiatal hernia (diaphragmatic hernia) is observed mainly in patients above 60. In connective tissue structures, strengthening esophagus in opening of diaphragm, degenerative changes occur, they lose their elasticity, atrophy. Similar situation may occur in untrained, asthenic people, as well as in individuals with congenital weakness of connective tissue structures (such as flat feet, Marfan syndrome, and others).

As a result of degenerative processes in involutive ligaments and tissues of hiatal there is its a significant extension and "hernial gate" is formed through which abdominal esophagus or adjacent part of stomach can penetrate into chest cavity.

Increased intra-abdominal pressure

Increase intra-abdominal pressure plays huge role in development of diaphragmatic hernia and may be considered in some cases as direct cause of disease. High intra-abdominal pressure contributes to weakness of ligamentous apparatus and hiatal tissue and penetration of abdominal esophagus through hernial into chest cavity.

Increased intra-abdominal pressure is observed during pronounced flatulence, pregnancy, uncontrollable vomiting, severe and persistent cough (chronic nonspecific pulmonary diseases), ascites, in presence of abdominal large tumors, with sharp and prolonged muscle tension of anterior abdominal wall, severe obesity.

Among these reasons persistent cough plays particularly important role. It is known that in 50% of patients with chronic obstructive bronchitis hiatal hernia is found.

Traction of esophageal up at dyskinesia of digestive system and diseases of esophagus

Dyskinesias of digestive tract, particularly of esophagus, are widespread in population. With hypermotor dyskinesias his esophageal longitudinal cuts cause traction (pulling) of esophagus up and may thus contribute to development of hiatal hernia, especially if its tissues are weakened. Functional esophageal disease (dyskinesia) occurs very often in gastric ulcer and 12 duodenal ulcers, chronic cholecystitis, chronic pancreatitis and other diseases of digestive system.

Perhaps this is why with these diseases hiatal hernia is often observed.

Triad Kasten (hiatal hernia, chronic cholecystitis, peptic ulcer of 12 duodenal ulcers) and Triad Saynta (hiatal hernia, chronic cholecystitis, diverticulitis of colon) are known.

Traction mechanism of hiatal hernia is important in such diseases of esophagus, as chemical and thermal esophageal ulcers, peptic esophageal ulcer, reflux esophagitis, and others. In this there is shortening of esophagus due to scar-inflammatory process and traction of it up ("pulling" into thoracic cavity).

In development of hiatal hernia there is sequence of penetration into chest cavity of various parts of esophagus and stomach - first abdominal esophagus, cardia, and then upper part of stomach.

In initial stages hiatal hernia is sliding (timely), i.e. transition of abdominal esophagus into chest cavity occurs intermittently, usually at time of sharp rise in intra-abdominal pressure. As a rule, displacement of abdominal esophagus into chest cavity promotes weak lower esophageal sphincter and thus, gastroesophageal reflux disease and reflux oesophagitis.

Symptoms of diaphragmatic hernia

In most patients, sliding hiatal hernia is asymptomatic, but there may be chest pain and signs of reflux. Para esophageal hiatal hernia is generally asymptomatic, but unlike sliding hiatal hernia may be complicated by prejudice or strangulation. Hidden or massive gastrointestinal bleeding may complicate any type of hernia.

Diagnosis of diaphragmatic hernia

Diagnosis of diaphragmatic hernia is based on the use of instrumental methods, methods of clinical examination of patient and differential diagnosis of this disease.

X-ray diagnosis of diaphragmatic hernia

Large fixed diaphragmatic hernia has the following characteristic radiographic signs:

• before contrast mass in posterior mediastinum accumulation of gas is defined, which is surrounded by narrow strip of wall hernia sac;
• after administration of barium sulfate filling of precipitated part of stomach in chest cavity is determined;
• location of hiatal forms "notchs" on contours of stomach.

Small axial diaphragmatic hernia is detected mainly in horizontal position of patient on his stomach. Its main symptoms are:

• high localization of upper esophageal sphincter (place of transition of tubular esophagus in its vial);
• location of cardia above hiatal, presence of several winding folds of mucous membrane of stomach in supradiaphragmatic formation (esophageal folds are narrower and their number is less);
• filling of axial hernia by contrast from esophagus.

Para esophageal diaphragmatic hernia has the following characteristic features:

• esophagus is well filled by contrasting mass, then contrast passes  by hernia and reaches cardia, which is located at the level of esophageal opening or below it;
• barium slurry from stomach flows into hernia (portion of stomach), i.e. from abdominal cavity into chest, it can be clearly seen in vertical, and especially - horizontal position of patient;
• with infringement of fundus para esophageal hernia gas bubble in mediastinum increases sharply on its background there is horizontal level of liquid contents of hernia.

Fiberoptic esophagogastroduodenoscopy

At esophagoscopy incompetence of cardia is determined, hernia cavity is clearly visible, reduction in distance between front incisors to cardia (less than 39-41 cm) is also a sign of diaphragmatic hernia.

Esophageal mucosa is usually inflamed, erosion, peptic ulcer is possible.

Esophageal motility study

Axial diaphragmatic hernia is characterized by expansion of lower zone of high pressure above diaphragm; lower zone of high pressure moves proximally hiatal. Localization of hiatal is detected by reversing phenomenon of tidal waves that is by change of direction of vertex respiratory teeth from positive into negative (V.X. Vasilenko, A.L. Grebenev, 1978).

Cardiofundal and subtotal stomach hernias of large sizes have two zones of high pressure: first - during passage of balloon through hiatal; second - is aligned with lower esophageal sphincter position, which is offset proximally.

Differential diagnosis of diaphragmatic hernia

Diaphragmatic hernia is differentiated from all diseases of digestive system, manifested by pain in epigastric and chest, heartburn, regurgitation, vomiting, dysphagia. Thus, diaphragmatic hernia should be differentiated from chronic gastritis, peptic ulcer disease, chronic pancreatitis, bowel disease, inflammatory diseases of biliary tract. It is necessary to carefully analyze symptoms of these diseases (set out in relevant chapters) and perform FEGDS and X-rays of stomach, which almost always allow diagnosing or excluding diaphragmatic hernia.

Sometimes it is necessary to differentiate diaphragmatic hernia with relaxation or paralysis of diaphragm (Petit’s disease). With relaxation of diaphragm its resistance decreases, and abdominal organs are displaced in thoracic cavity, but unlike diaphragmatic hernia, are located still not above but below diaphragm.

Relaxation of diaphragm can be congenital and acquired, right- and left, partial and full. With diaphragmatic hernia relaxation of left dome of diaphragm is usually necessary to be differentiated. With this stomach and colon move up (splenic angle, sometimes part of transverse colon), stomach is significantly deformed, its bend occurs, imitating cascade -like stomach.

Main symptoms of relaxation of left dome of diaphragm are as follows:

• feeling of heaviness in epigastrium after eating;
• dysphagia;
• belching;
• nausea, sometimes vomiting ;
• heartburn;
• palpitations and shortness of breath;
• dry cough;
• at X-ray examination persistent increase in level of left dome of diaphragm is determined. With breathing left dome of diaphragm performs both normal movement (drops on inspiration, rises as you exhale), and paradoxical movement (rising on breath, dropping at exhale), but range of motion is limited;
• darkening of bottom margin of left lung and heart shadow offset to right are marked;
• gas bubble of stomach and splenic flexure of colon are although moved in thoracic cavity, but are located under diaphragm.

Often diaphragmatic hernia is differentiated with coronary heart disease (presence of chest pain, cardiac arrhythmias). Pain at height of physical or emotional load, frequent pain irradiating into left arm, left shoulder, ischemic changes at ECG are characteristic features of coronary artery disease (as opposed to diaphragmatic hernia ). For chest pain due to diaphragmatic hernia, its occurrence in horizontal position is characteristic, pain reliefs in vertical position and after taking alkali, there is severe postprandial heartburn, absence of ischemic electrocardiographic changes. However, we should not forget that combination of coronary artery disease and diaphragmatic hernia is possible, and diaphragmatic hernia can exacerbate coronary artery disease.

Treatment of diaphragmatic hernia

Asymptomatic sliding hiatal hernia (diaphragmatic hernia) does not require any specific treatment. Patients with concomitant GERD need treatment. Para esophageal hernia of esophagus requires surgical treatment because of risk of infringement.