Diaphragmatic hernia

A hernia of the esophageal opening of the diaphragm (diaphragmatic hernia) is a chronic recurrent disease of the digestive system associated with the displacement of the diaphragm through the esophageal opening into the chest cavity (posterior mediastinum) of the abdominal esophagus, cardia, upper stomach, and sometimes bowels. It is a protrusion of the stomach through the esophageal opening of the diaphragm. Most hernias are asymptomatic, but the progression of acid reflux can cause symptoms of gastroesophageal reflux disease (GERD). The diagnosis is established by fluoroscopy with a sip of barium. Symptomatic treatment if signs of GERD are present.

[1], [2], [3], [4]

Epidemiology

Hiatal hernia (diaphragmatic hernia) is a very common disease. It occurs in 0.5% of the total adult population, and in 50% of patients it does not produce any clinical manifestations and, therefore, is not diagnosed.

[5], [6], [7], [8], [9], [10]

Causes of the diaphragmatic hernia

The cause of the diaphragmatic hernia is unknown, but it is believed that a hiatal hernia may occur due to stretching of the fascial ligaments between the esophagus and the aperture of the diaphragm (the opening of the diaphragm through which the esophagus passes). With a sliding hernia of the esophageal opening of the diaphragm, the most frequent type is the exit of the gastroesophageal junction and part of the stomach above the diaphragm. With paraesophageal hernia of the esophageal opening of the diaphragm, the gastroesophageal junction is in a normal position, but part of the stomach is adjacent to the esophagus. Hernias can also come out through other defects of the diaphragm.

Sliding diaphragmatic hernia is common and randomly diagnosed during an X-ray examination in more than 40% of the population. Therefore, the relationship of the hernia to the symptoms is unclear. Although most patients with GERD have a certain percentage of hiatus hernias, less than 50% of patients with hiatal hernia suffer GERD.

Pathogenesis

As you know, the esophagus passes through the esophageal opening of the diaphragm, before it enters the cardial region of the stomach. The esophageal opening of the diaphragm and the esophagus are connected by a very thin connective tissue membrane, which hermetically separates the abdominal cavity from the chest. The pressure in the abdominal cavity is higher than in the chest, so with certain additional conditions, this membrane stretches and the abdominal part of the esophagus with a part of the cardial part of the stomach can move into the chest cavity, forming a diaphragmatic hernia.

In the development of a hernia of the esophageal opening of the diaphragm (diaphragmatic hernia), three groups of factors play a crucial role:

• weakness of connective tissue structures that strengthen the esophagus in the opening of the diaphragm;
• increased abdominal pressure;
• traction of the esophagus up in dyskinesia of the digestive tract and diseases of the esophagus.

Weakness of connective tissue structures that strengthen the esophagus in the opening of the diaphragm

The weakness of the ligament apparatus and the esophageal orifice tissue develops with an increase in the person’s age due to involutive processes, therefore hernia of the esophageal orifice (diaphragmatic hernia) is observed mainly in patients over 60 years of age. In connective tissue structures that strengthen the esophagus in the aperture of the diaphragm, dystrophic changes occur, they lose elasticity, atrophy. The same situation can occur in untrained, asthenized people, as well as in individuals with congenital weakness of connective tissue structures (for example, flatfoot, Marfan syndrome, etc.).

Due to dystrophic involutive processes in the ligamentous apparatus and tissues of the esophageal opening of the diaphragm, its significant expansion occurs, and "hernial gates" are formed, through which the abdominal esophagus or the adjacent part of the stomach can penetrate into the chest cavity.

[11], [12], [13], [14], [15], [16]

Increased intra-abdominal pressure

Increased abdominal pressure plays a huge role in the development of diaphragmatic hernia and can in some cases be considered as the immediate cause of the disease. High intra-abdominal pressure contributes to the weakness of the ligamentous apparatus and the esophageal opening of the diaphragm and the penetration of the abdominal esophagus through the hernial ring into the chest cavity.

Increased intra-abdominal pressure is observed with pronounced flatulence, pregnancy, uncontrollable vomiting, severe and persistent coughing (with chronic nonspecific lung diseases), ascites, with large tumors in the abdominal cavity, with a strong and prolonged tension of the muscles of the anterior abdominal wall, severe obesity.

Among these reasons, a persistent cough plays a particularly important role. It is known that in 50% of patients with chronic obstructive bronchitis a hernia of the esophageal opening of the diaphragm is detected.

[17], [18], [19], [20], [21], [22], [23], [24], [25]

Traction of the esophagus up with dyskinesia of the digestive tract and diseases of the esophagus

Dyskinesia of the digestive tract, in particular, the esophagus is widely distributed among the population. When hypermotor dyskinesia of the esophagus, its longitudinal contractions cause traction (pulling up) of the esophagus upward and may thus contribute to the development of a hernia of the esophageal opening of the diaphragm, especially if its tissues are weak. Functional diseases of the esophagus (dyskinesia) are observed very often with gastric ulcer and 12 duodenal ulcer, chronic cholecystitis, chronic pancreatitis and other diseases of the digestive system. It is possible therefore at the named diseases hernias of the esophageal opening of the diaphragm are often observed.

Known are Kasten's triad (hernia of the esophageal orifice of the diaphragm, chronic cholecystitis, duodenal ulcer) and Saynt's triad (hernia of the esophageal orifice of the diaphragm, chronic cholecystitis, colon diverticulum).

The traction mechanism of the formation of a hernia of the esophageal orifice of the diaphragm is important in such diseases of the esophagus as chemical and thermal ulcers of the esophagus, peptic esophageal ulcer, reflux esophagitis, etc. At the same time, shortening of the esophagus occurs as a result of the scar-inflammatory process and traction upwards (“pulling up” into the chest cavity).

In the process of development of the hernia of the esophageal orifice of the diaphragm, a sequence of penetration into the chest cavity of various parts of the esophagus and stomach is noted - first the abdominal esophagus, then the cardia and then the upper stomach. In the initial stages, hernia of the esophageal opening of the diaphragm is gliding (temporary), i.e. Transition of the abdominal part of the esophagus into the chest cavity occurs periodically, as a rule, at the time of a sharp increase in intra-abdominal pressure. As a rule, the displacement of the abdominal esophagus into the chest cavity contributes to the development of weakness of the lower esophageal sphincter and, therefore, gastroesophageal reflux and reflux esophagitis.

Symptoms of the diaphragmatic hernia

In most patients, sliding hiatal hernia is asymptomatic, but chest pain and other signs of reflux may occur. Paraesophageal hernia of the esophageal orifice of the diaphragm is generally asymptomatic, but, unlike sliding hernia of the esophageal orifice of the diaphragm, it can be restrained and complicated by strangulation. Hidden or massive bleeding can complicate any type of hernia.

In 50% of cases, diaphragmatic hernia can occur latently or with very minor symptoms and simply turn out to be an accidental finding during X-ray or endoscopic examination of the esophagus and stomach. Quite often (in 30-35% of patients), cardiac arrhythmias (extrasystoles, paroxysmal tachycardia) or pain in the region of the heart (non-coronary cardiogy), which cause diagnostic errors and unsuccessful treatment by a cardiologist, come to the fore in the clinical picture.

The most characteristic clinical symptoms of diaphragmatic hernia are as follows.

[26]

Pain

Most often, the pain is localized in the epigastric region and spreads along the esophagus, less often there is an irradiation of pain in the back and interscapular region. Sometimes there is a pain of shingles, which leads to an erroneous diagnosis of pancreatitis.

In approximately 15–20% of patients, pain is localized in the region of the heart and is taken for angina pectoris or even myocardial infarction. It should also be noted that a combination of diaphragmatic hernia and coronary artery disease is possible, especially since diaphragmatic hernia occurs more often in old age, which is also characterized by coronary artery disease.

Very important in the differential diagnosis of pain arising from diaphragmatic hernia, is the consideration of the following circumstances:

• pain most often occurs after eating, especially abundant, during physical exertion, weight lifting, coughing, flatulence, in a horizontal position;
• pain disappears or decreases after belching, vomiting, after a deep breath, going upright, and taking alkalis, water;
• pains are rarely extremely strong; most often they are moderate, dull
• pains worse when bending forward.

The origin of pain in diaphragmatic hernia is due to the following main mechanisms:

• compression of the nervous and vascular endings of the cardia and the fundus of the stomach in the region of the esophageal opening of the diaphragm when they penetrate into the chest cavity;
• acid-peptic aggression of gastric and duodenal contents;
• stretching of the esophagus walls with gastroesophageal reflux;
• hypermotor dyskinesia of the esophagus, the development of cardiospasm;
• in some cases pylorospasm develops.

In the event of the addition of complications, the nature of the pain during diaphragmatic hernia changes. For example, during the development of solarium, epigastric pains become stubborn, intense, become burning in nature, intensify with pressure on the projection area of the solar plexus, weaken in the knee-elbow position and when bending forward. After eating a significant change in pain does not occur. With the development of periviscerita, the pains become dull, aching, constant, they are localized high in the epigastrium and the xiphoid process of the sternum.

When a hernial sac is strangulated in the hernial ring, persistent intense pain behind the sternum is characteristic, sometimes tingling, radiating to the interscapular region.

[27], [28], [29]

Cardia insufficiency, gastroesophageal reflux, reflux esophagitis

In diaphragmatic hernia, gastroesophageal reflux disease naturally develops.

This group includes the following symptoms of diaphragmatic hernia:

• belching acidic gastric contents, often with an admixture of bile, which creates a taste of bitterness in the mouth. Burping with air is possible. Belching occurs soon after eating and is often very pronounced. According to V. X. Vasilenko and A. L. Grebeneva (1978), the severity of belching depends on the type and diaphragmatic hernia. With a cardiofundal fixed hernia, belching is very pronounced. With unfixed cardiofundal or fixed cardiac diaphragmatic hernia, belching is less pronounced;
• regurgitation (regurgitation) - appears after eating, usually in a horizontal position, often at night ("a symptom of a wet pillow"). Most often, regurgitation occurs with food taken recently or with acidic gastric contents. Sometimes the volume of regurgitated masses is quite large and can lead to the development of aspiration pneumonia. Burping is most characteristic of cardiofundal and cardiac diaphragmatic hernia. Regurgitation due to contractions of the esophagus, not preceded by nausea. Sometimes the regurgitated contents are chewed and swallowed again;
• dysphagia - difficulty passing food through the esophagus. Dysphagia is not a permanent symptom, it can appear and disappear. Characteristic of diaphragmatic hernia is that dysphagia is most often observed when consuming liquid or semi-liquid food and is triggered by the intake of too hot or too cold water, hasty food, or psycho-traumatic factors. Solid food passes through the esophagus somewhat better (Lichtenstern's paradoxical dysphagia). If dysphagia becomes permanent and loses its “paradoxical” character, differential diagnosis with esophageal cancer should be made, and suspected complications of diaphragmatic hernia (incarceration of the hernia, development of peptic ulcer of the esophagus, esophageal stricture) should be suspected;
• chest pain when swallowing food - appears in the case when the diaphragmatic hernia is complicated by reflux esophagitis; as cupping esophagitis, pain decreases;
• Heartburn is one of the most frequent symptoms of diaphragmatic hernia, especially axial hernias. Heartburn is observed after eating, in a horizontal position, and especially often occurs at night. In many patients, heartburn is very pronounced and can become the leading symptom of diaphragmatic hernia;
• hiccups - can occur in 3-4% of patients with diaphragmatic hernia, mainly in axial hernias. A characteristic feature of hiccups is its duration (several hours, and in the most severe cases - even several days) and dependence on eating. The origin of hiccups is explained by irritation of the phrenic nerve with a hernial sac and inflammation of the diaphragm (diaphragmatitis);
• burning and pain in the tongue - an infrequent symptom with diaphragmatic hernia, may be due to the throwing of gastric or duodenal contents into the oral cavity, and sometimes even into the larynx (a kind of "peptic burn" of the tongue and larynx). This phenomenon causes the appearance of pain in the tongue and often hoarseness;
• frequent combination of diaphragmatic hernia with the pathology of the respiratory organs - tracheobronchitis, obstructive bronchitis, attacks of bronchial asthma, aspiration pneumonia (broncho esophageal syndrome). Among these manifestations, aspiration of the gastric contents into the respiratory tract is particularly important. As a rule, this is observed at night, during sleep, if, shortly before bedtime, the patient drank plentifully. There is an attack of persistent cough, often it is accompanied by suffocation and pain behind the sternum.

[30], [31], [32], [33], [34], [35], [36], [37]

Objective study of the patient

At the location of the stomach with the air bubble in the chest cavity, it can be detected with percussion tympanic sound in the paravertebral space on the left.

[38], [39], [40], [41], [42], [43], [44], [45], [46]

Anemic syndrome

It is advisable to single out this syndrome as the most important in the clinical picture, since it often comes to the fore and masks the remaining manifestations of diaphragmatic hernia. As a rule, anemia is associated with repeated hidden hemorrhages from the lower esophagus and stomach, caused by reflux esophagitis, erosive gastritis, and sometimes peptic ulcers of the lower esophagus. Anemia is iron deficient and is manifested by all its characteristic symptoms . The most significant clinical signs of iron deficiency anemia are: weakness, dizziness, darkening of the eyes, pale skin and visible mucous membranes, sideropenia syndrome (dry skin, trophic changes in the nails, taste perversion, smell), low iron content in the blood, erythrocyte hypochromia, anisocytosis, anesthetics, low erythrocytes, anisocytosis, anomalies., decrease in hemoglobin and red blood cells, low color figure.

[47], [48]

Forms

The unified classification of hiatal hernia (diaphragmatic hernia) does not exist. The most relevant are the following:

[49]

Classification based on anatomical features

The following three options are distinguished:

1. Sliding (axial, axial) hernia. It is characterized by the fact that the abdominal part of the esophagus, cardia, and fundus of the stomach can freely enter the chest cavity through the enlarged esophageal opening of the diaphragm and return back to the abdominal cavity (when the patient's position changes).
2. Paraesophageal hernia. In this variant, the terminal part of the esophagus and cardia remain under the diaphragm, but part of the fundus of the stomach penetrates the chest cavity and is located next to the thoracic esophagus (paraesophageal).
3. Mixed hernia. At the mixed option of diaphragmatic hernia a combination of axial and paraesophageal hernia is observed.

[50], [51], [52], [53], [54], [55]

Classification depending on the volume of penetration of the stomach into the chest cavity

The basis of this classification are radiological manifestations of the disease. There are three degrees of diaphragmatic hernia.

• Diaphragmatic hernia I degree - in the chest cavity (above the diaphragm) is the abdominal esophagus, and Cardia - at the level of the diaphragm, the stomach is elevated and directly adjacent to the diaphragm.
• A diaphragmatic hernia of the II degree - the abdominal part of the esophagus is located in the chest cavity, and directly in the region of the esophageal opening of the diaphragm is already a part of the stomach.
• Diaphragmatic hernia III degree - above the diaphragm are the abdominal esophagus, cardia and part of the stomach (bottom and body, and in severe cases even the antrum).

[56], [57], [58], [59], [60], [61], [62], [63],

Clinical classification

A. Type of hernia

• fixed or unfixed (for axial and paraesophageal hernia);
• axial - esophageal, cardiofundal, subtotal and total gastric;
• paraesophageal (fundal, antral);
• congenital short esophagus with "chest stomach" (developmental abnormality);
• hernias of another type (enteric, omental, etc.).

B. Complications of diaphragmatic hernia

1. Reflux esophagitis
   1. morphological characteristics - catarrhal, erosive, ulcerative
   2. peptic ulcer of the esophagus
   3. inflammatory cicatricial stenosis and / or shortening of the esophagus (acquired shortening of the esophagus), the degree of their severity
2. Acute or chronic esophageal (esophageal-gastric) bleeding
3. Retrograde prolapse of the gastric mucosa into the esophagus
4. Invagination of the esophagus into the hernial part
5. Perforation of the esophagus
6. Reflex angina
7. Infringement of a hernia (with paraesophageal hernia)

B. The putative cause of diaphragmatic hernia

Dyskinesia of the digestive tract, increased intra-abdominal pressure, age-related weakening of connective tissue structures, etc. The mechanism of hernia: pulsion, traction, mixed.

G. Concomitant diseases

D. The severity of reflux esophagitis

• Mild form: weak severity of symptoms, sometimes its absence (in this case, the presence of esophagitis is ascertained on the basis of x-ray data of the esophagus, esophagoscopy, and targeted biopsy).
• Medium severity: the symptoms of the disease are clearly expressed, there is a worsening of general well-being and a decrease in working ability.
• Severe: severe symptoms of esophagitis and the addition of complications - primarily peptic structures and cicatricial shortening of the esophagus.

[64], [65], [66]

Complications and consequences

• Chronic gastritis and ulcers of the hernial part of the stomach develops with a long-existing diaphragmatic hernia. The symptoms of these complications, of course, are masked by the manifestations of the hernia itself. Finally, the diagnosis is verified using gastroscopy and fluoroscopy of the esophagus and stomach. Kay's syndrome is known - hernia of the esophageal opening of the diaphragm, gastritis and ulcer in that part of the stomach, which is located in the chest cavity.
• Bleeding and anemia. Severe gastric bleeding is observed in 12-18%, hidden - in 22-23% of cases. The cause of bleeding are peptic ulcers, erosion of the esophagus and stomach. Chronic hidden blood loss leads to the development of most often iron deficiency anemia. Rarely developing B _{12 -} deficiency anemia due to atrophy of the fundus of the stomach and cessation of gastromucoprotein production.
• Pinching of the hiatus hernia is the most serious complication. The clinical picture of infringement of diaphragmatic hernia has the following symptoms:
  • severe colicy pains in the epigastrium and left hypochondrium (pains somewhat lessen in the position on the left side);
  • nausea, vomiting with blood;
  • shortness of breath, cyanosis, tachycardia, a drop in blood pressure;
  • bulging of the lower part of the chest, lagging it when breathing;
  • a boxed sound or tympanitis and a sharp weakening or lack of breathing in the lower lung on the affected side; noise of intestinal peristalsis is sometimes determined;
  • radiographically, it is possible to detect a displacement of the mediastinum in a healthy direction.

When paraesophageal hernia is strangulated, Borri syndrome develops - a tympanic tone of sound during percussion of the paravertebral space on the left at the level of the thoracic vertebrae, shortness of breath, dysphagia, and delayed contrast during the passage through the esophagus.

• Reflux esophagitis is a natural and frequent complication of diaphragmatic hernia.

The remaining complications of diaphragmatic hernia - retrograde prolapse of the gastric mucosa into the esophagus, invagination of the esophagus into the hernial part are rarely observed and are diagnosed by fluoroscopy and endoscopy of the esophagus and stomach.

[67], [68], [69], [70], [71], [72], [73]

Diagnostics of the diaphragmatic hernia

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

X-ray diagnosis of diaphragmatic hernia

Large fixed diaphragmatic hernia has the following characteristic radiographic signs:

• before receiving a contrasting mass in the posterior mediastinum, gas accumulation is determined, which is surrounded by a narrow strip of the hernial sac wall;
• after taking barium sulfate, the filling of the part of the stomach that has fallen into the chest cavity is determined;
• the location of the esophageal opening of the diaphragm forms "notches" on the contours of the stomach.

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

• high localization of the upper esophageal sphincter (the place of passage of the tubular part of the esophagus into its ampulla);
• the location of the cardia above the esophageal opening of the diaphragm; the presence of several convoluted folds of the gastric mucosa in the epiphiscial formation (the esophageal folds are narrower and their number is less);
• filling the axial hernia with esophageal contrast.

Paraesophageal diaphragmatic hernia has the following characteristics:

• the esophagus is well filled with a contrasting mass, then the contrast passes by the hernia and reaches the cardia, which is located at or below the level of the esophageal opening;
• barium suspension from the stomach enters the hernia (part of the stomach), i.e. From the abdominal cavity to the chest, it is clearly visible in the vertical and especially - the horizontal position of the patient;
• at infringement of fundus paraesophageal hernia, the gas bladder in the mediastinum sharply increases, a horizontal level of the liquid contents of the hernia appears on its background.

[74], [75], [76], [77]

FAMILY

When esophagoscopy is determined by the failure of the cardia, the hernia cavity is clearly visible, a sign of diaphragmatic hernia is also a decrease in the distance from the front incisors to the cardia (less than 39-41 cm).

The mucous membrane of the esophagus, usually inflamed, may be eroded, peptic ulcer.

[78], [79], [80], [81]

Esophagomanometry

Axial diaphragmatic hernia characterized by the expansion of the lower zone of high pressure above the diaphragm; the lower pressure zone is displaced proximal to the esophageal opening of the diaphragm. Localization of the esophageal opening of the diaphragm is established by the phenomenon of respiratory wave reversion i.e. By changing the direction of the vertices of the respiratory teeth from positive to negative (V. X. Vasilenko, A. L. Grebenev, 1978).

Cardiofundal and subtotal-gastric hernias of a large size have two zones of increased pressure: the first is when the balloon passes through the esophageal opening of the diaphragm; the second corresponds to the location of the lower esophageal sphincter, which is displaced proximally.

[82], [83]

Differential diagnosis

Diaphragmatic hernia is differentiated with all diseases of the digestive system, manifested by pain in the epigastrium and behind the sternum, heartburn, belching, vomiting, dysphagia. Thus, diaphragmatic hernia should be differentiated from chronic gastritis, peptic ulcer disease, chronic pancreatitis, diseases of the large intestine, inflammatory diseases of the biliary tract. At the same time, it is necessary to carefully analyze the symptoms of these diseases (it is presented in the relevant chapters) and to produce FGDS and gastric fluoroscopy, which almost always allow us to confidently diagnose or exclude diaphragmatic hernia.

Sometimes diaphragmatic hernia is necessary to differentiate with relaxation or paralysis of the diaphragm (Petit's disease). When the diaphragm relaxes, its resistance decreases, and the abdominal organs are displaced into the chest cavity, but unlike the diaphragmatic hernia, they are located not above, but under the diaphragm.

Relaxation of the diaphragm is congenital and acquired, right- and left-sided, partial and complete. With diaphragmatic hernia, it is usually necessary to differentiate the relaxation of the left dome of the diaphragm. At the same time, the stomach and the large intestine (splenic angle, sometimes part of the transverse colon) move upwards, and the stomach is significantly deformed, it bends, resembling a cascade stomach.

The main symptoms of relaxation of the left dome of the diaphragm are as follows:

• feeling of heaviness in the epigastrium after eating;
• dysphagia;
• belching;
• nausea, sometimes vomiting;
• heartburn;
• palpitations and shortness of breath;
• dry cough;
• X-ray examination determines a persistent increase in the level of the left dome of the diaphragm. When breathing, the left dome of the diaphragm performs both normal movements (descends on inspiration, rises on expiration), and paradoxical movements (rises on inspiration, descends on expiration), but the amplitude of movements is limited;
• darkening of the lower field of the left lung and displacement of the heart shadow to the right is noted;
• the gas bubble of the stomach and the splenic flexure of the large intestine, although displaced into the chest cavity, are located under the diaphragm.

Quite often, diaphragmatic hernia is differentiated with ischemic heart disease (in the presence of chest pains, cardiac arrhythmias). Distinctive signs characteristic of CHD (as opposed to diaphragmatic hernia) are the occurrence of pain at the height of physical or psycho-emotional stress, frequent irradiation of pain in the left arm, left scapula, ischemic changes on the ECG. For retrosternal pain caused by diaphragmatic hernia, characterized by its appearance in a horizontal position, relief of pain in an upright position and after taking alkalis, the presence of severe heartburn that occurs after eating, the absence of ischemic changes on the ECG. However, one should not forget that a combination of IHD and diaphragmatic hernia is possible, and that diaphragmatic hernia can cause an exacerbation of IHD.

[84], [85],

Treatment of the diaphragmatic hernia

Asymptomatically proceeding sliding hernia of the esophageal opening of the diaphragm (diaphragmatic hernia) does not require any specific therapy. Patients with concomitant GERD need treatment. Paraesophageal hernia of the esophagus requires surgical treatment because of the risk of infringement.