Diaphragmatic hernia

A hernia of the esophageal opening of the diaphragm (diaphragmatic hernia) is a chronic recurring disease of the digestive system associated with the displacement of the abdominal esophagus, cardia, upper stomach, and sometimes intestinal loops through the esophageal opening of the diaphragm into the chest cavity (posterior mediastinum). 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). Diagnosis is established by X-ray with a barium swallow. Treatment is symptomatic if signs of GERD are present.

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Epidemiology

Hernia of the esophageal opening of the diaphragm (diaphragmatic hernia) is a very common disease. It occurs in 0.5% of the entire adult population, and in 50% of patients it does not give any clinical manifestations and, therefore, is not diagnosed.

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Causes diaphragmatic hernia

The cause of diaphragmatic hernia is unknown, but it is thought that a hiatal hernia may occur due to stretching of the fascial ligaments between the esophagus and the hiatus diaphragmaticus (the opening in the diaphragm through which the esophagus passes). In a sliding hiatal hernia, the most common type is where the gastroesophageal junction and part of the stomach exit above the diaphragm. In a paraesophageal hiatal hernia, the gastroesophageal junction is in its normal position, but part of the stomach is adjacent to the esophagus. Hernias may also exit through other defects in the diaphragm.

Sliding diaphragmatic hernia is common and is incidentally diagnosed on x-ray in more than 40% of the population. Therefore, the relationship of the hernia to symptoms is unclear. Although most patients with GERD have some percentage of hiatal hernias, less than 50% of patients with a hiatal hernia have GERD.

Pathogenesis

As is known, the esophagus passes through the esophageal opening of the diaphragm before entering the cardiac section 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 under certain additional conditions, this membrane stretches, and the abdominal part of the esophagus with part of the cardiac section of the stomach can shift 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 decisive role:

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

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

Weakness of the ligamentous apparatus and tissues of the esophageal opening of the diaphragm develops with increasing age of a person due to involution processes, therefore, a hernia of the esophageal opening of the diaphragm (diaphragmatic hernia) is observed mainly in patients over 60 years old. Dystrophic changes occur in the connective tissue structures that strengthen the esophagus in the opening of the diaphragm, they lose elasticity, and atrophy. The same situation can occur in untrained, asthenic people, as well as in people with congenital weakness of connective tissue structures (for example, flat feet, Marfan syndrome, etc.).

As a result of dystrophic involutional processes in the ligamentous apparatus and tissues of the esophageal opening of the diaphragm, its significant expansion occurs, and a “hernial orifice” is formed, through which the abdominal part of the esophagus or the adjacent part of the stomach can penetrate into the chest cavity.

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Increased intra-abdominal pressure

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

Increased intra-abdominal pressure is observed with severe flatulence, pregnancy, uncontrollable vomiting, severe and persistent cough (with chronic non-specific lung diseases), ascites, the presence of large tumors in the abdominal cavity, with sudden and prolonged tension of the muscles of the anterior abdominal wall, and severe obesity.

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

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Esophageal traction upwards in cases of gastrointestinal dyskinesia and esophageal diseases

Dyskinesia of the digestive tract, in particular, of the esophagus, is widespread among the population. In hypermotor dyskinesia of the esophagus, its longitudinal contractions cause traction (pulling) of the esophagus upward and can thus contribute to the development of a hernia of the esophageal opening of the diaphragm, especially in the presence of weakness of its tissues. Functional diseases of the esophagus (dyskinesia) are very often observed in gastric ulcer and duodenal ulcer, chronic cholecystitis, chronic pancreatitis and other diseases of the digestive system. Perhaps this is why hernias of the esophageal opening of the diaphragm are often observed in the above-mentioned diseases.

The Kasten triad (esophageal hernia of the diaphragm, chronic cholecystitis, duodenal ulcer) and the Saint triad (esophageal hernia of the diaphragm, chronic cholecystitis, diverticulum of the colon) are known.

The traction mechanism of the formation of a hernia of the esophageal opening 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. In this case, the esophagus shortens as a result of the cicatricial inflammatory process and is tractioned upwards (“pulled” into the chest cavity).

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

Symptoms diaphragmatic hernia

Most patients with sliding hiatal hernias are asymptomatic, but chest pain and other signs of reflux may be present. Paraesophageal hiatal hernias are generally asymptomatic, but unlike sliding hiatal hernias, they may become strangulated and complicated by strangulation. Occult or massive gastrointestinal bleeding may complicate any type of hernia.

In 50% of cases, a diaphragmatic hernia may proceed latently or with very minor symptoms and simply be an accidental finding during an X-ray or endoscopic examination of the esophagus and stomach. Quite often (in 30-35% of patients), cardiac arrhythmia (extrasystole, paroxysmal tachycardia) or pain in the heart area (non-coronary cardialgia) come to the forefront of the clinical picture, which causes diagnostic errors and unsuccessful treatment by a cardiologist.

The most characteristic clinical symptoms of diaphragmatic hernia are the following.

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Pain

Most often, the pain is localized in the epigastric region and spreads along the esophagus; less often, pain radiates to the back and interscapular region. Sometimes, pain of a girdle nature is observed, which leads to an erroneous diagnosis of pancreatitis.

In approximately 15-20% of patients, pain is localized in the heart area and is mistaken for angina or even myocardial infarction. It should also be taken into account that a combination of diaphragmatic hernia and coronary heart disease is possible, especially since diaphragmatic hernias often occur in old age, which is also characterized by coronary heart disease.

It is very important in the differential diagnosis of pain arising from a diaphragmatic hernia to take into account the following circumstances:

• pain most often appears after eating, especially large meals, during physical exertion, lifting weights, coughing, flatulence, in a horizontal position;
• the pain disappears or decreases after belching, vomiting, taking a deep breath, moving to a vertical position, and also after taking alkalis and water;
• the pains are rarely extremely severe; most often they are moderate and dull
• the pain intensifies when leaning forward.

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

• compression of the nerve and vascular endings of the cardia and fundus of the stomach in the area 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 esophageal walls in gastroesophageal reflux;
• hypermotor dyskinesia of the esophagus, development of cardiospasm;
• In some cases, pylorospasm develops.

In case of complications, the nature of pain in diaphragmatic hernia changes. For example, with the development of solaritis, pain in the epigastrium becomes persistent, intense, acquires a burning character, intensifies with pressure on the projection area of the solar plexus, weakens in the knee-elbow position and when bending forward. After eating, there is no significant change in the pain syndrome. With the development of perivisceritis, the pain becomes dull, aching, constant, they are localized high in the epigastrium and the area of the xiphoid process of the sternum.

When the hernial sac is strangulated in the hernial orifice, constant intense pain behind the sternum is characteristic, sometimes of a stabbing nature, radiating to the interscapular region.

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Cardiac insufficiency, gastroesophageal reflux, reflux esophagitis

With a diaphragmatic hernia, gastroesophageal reflux disease naturally develops.

The following symptoms of diaphragmatic hernia belong to this group:

• belching of sour gastric contents, often mixed with bile, which creates a bitter taste in the mouth. Belching of air is possible. Belching occurs soon after eating and is often very pronounced. According to V. Kh. Vasilenko and A. L. Grebenev (1978), the severity of belching depends on the type of diaphragmatic hernia. With a fixed cardiofundal hernia, belching is very pronounced. With an unfixed cardiofundal or fixed cardiac diaphragmatic hernia, belching is less pronounced;
• regurgitation (belching) - occurs after eating, usually in a horizontal position, often at night ("wet pillow symptom"). Most often, regurgitation occurs with food eaten recently or with acidic gastric contents. Sometimes the volume of regurgitated masses is quite large and can lead to the development of aspiration pneumonia. Regurgitation is most typical for cardiofundal and cardiac diaphragmatic hernias. Regurgitation is caused by the esophagus's own contractions, it is not preceded by nausea. Sometimes the regurgitated contents are chewed and swallowed again;
• dysphagia - difficulty in passing food through the esophagus. Dysphagia is not a constant symptom, it can appear and disappear. A characteristic feature of diaphragmatic hernia is that dysphagia is most often observed when consuming liquid or semi-liquid food and is provoked by drinking too hot or too cold water, eating too quickly, or by psychotraumatic factors. Solid food passes through the esophagus somewhat better (Lichtenstern's paradoxical dysphagia). If dysphagia becomes constant and loses its "paradoxical" character, differential diagnostics with esophageal cancer should be carried out, and complications of diaphragmatic hernia should be suspected (strangulation of the hernia, development of a peptic ulcer of the esophagus, stricture of the esophagus);
• retrosternal pain when swallowing food - appears when a diaphragmatic hernia is complicated by reflux esophagitis; as the esophagitis subsides, the pain decreases;
• heartburn is one of the most common 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 expressed very significantly and can become the leading symptom of diaphragmatic hernia;
• hiccups - may occur in 3-4% of patients with diaphragmatic hernia, mainly with axial hernias. A characteristic feature of hiccups is their duration (several hours, and in the most severe cases - even several days) and dependence on food intake. The origin of hiccups is explained by irritation of the phrenic nerve by the hernial sac and inflammation of the diaphragm (diaphragmatitis);
• burning and pain in the tongue - an uncommon symptom of diaphragmatic hernia, may be caused by the reflux 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 pain in the tongue and often hoarseness;
• frequent combination of diaphragmatic hernia with respiratory pathology - tracheobronchitis, obstructive bronchitis, attacks of bronchial asthma, aspiration pneumonia (bronchoesophageal syndrome). Among the above manifestations, aspiration of gastric contents into the respiratory tract is especially important. As a rule, this is observed at night, during sleep, if the patient has had a large dinner shortly before bedtime. An attack of persistent coughing occurs, often accompanied by suffocation and pain behind the breastbone.

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Objective examination of the patient

When the vault of the stomach with the air bubble in it is located in the chest cavity, a tympanic sound can be detected in the paravertebral space on the left during percussion.

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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 other manifestations of diaphragmatic hernia. As a rule, anemia is associated with repeated hidden bleeding from the lower esophagus and stomach caused by reflux esophagitis, erosive gastritis, and sometimes peptic ulcers of the lower esophagus. Anemia is iron deficiency and manifests itself with all the symptoms characteristic of it. The most significant clinical signs of iron deficiency anemia: weakness, dizziness, darkening in the eyes, pale skin and visible mucous membranes, sideropenia syndrome (dry skin, trophic changes in the nails, perversion of taste, smell), low iron content in the blood, hypochromia of erythrocytes, anisocytosis, poikilocytosis, decreased hemoglobin and erythrocytes, low color index.

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Forms

There is no single classification of hernias of the esophageal opening of the diaphragm (diaphragmatic hernia). The most relevant are the following:

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Classification based on anatomical features

There are three different options:

1. Sliding (axial) hernia. It is characterized by the fact that the abdominal part of the esophagus, the cardia and the fundus of the stomach can freely penetrate into the chest cavity through the widened 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 the cardia remain under the diaphragm, but part of the fundus of the stomach penetrates into the chest cavity and is located next to the thoracic part of the esophagus (paraesophageal).
3. Mixed variant of hernia. In the mixed variant of diaphragmatic hernia, a combination of axial and paraesophageal hernias is observed.

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

This classification is based on radiological manifestations of the disease. There are three degrees of diaphragmatic hernia.

• Diaphragmatic hernia of the first degree - the abdominal part of the esophagus is located in the chest cavity (above the diaphragm), and the cardia is at the level of the diaphragm, the stomach is raised and directly adjacent to the diaphragm.
• Diaphragmatic hernia of the second degree - the abdominal part of the esophagus is located in the chest cavity, and directly in the area of the esophageal opening of the diaphragm is already part of the stomach.
• Diaphragmatic hernia grade III - the abdominal part of the esophagus, cardia and part of the stomach (fundus and body, and in severe cases even the antral part) are located above the diaphragm.

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Clinical classification

A. Type of hernia

• fixed or non-fixed (for axial and paraesophageal hernias);
• axial - esophageal, cardiofundal, subtotal and total gastric;
• paraesophageal (fundal, antral);
• congenital short esophagus with a "thoracic stomach" (developmental anomaly);
• other types of hernias (small intestinal, 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 (esophagogastric) bleeding
3. Retrograde prolapse of the gastric mucosa into the esophagus
4. Intussusception of the esophagus into the hernial part
5. Esophageal perforation
6. Reflex angina
7. Incarcerated hernia (in paraesophageal hernias)

B. Suspected cause of diaphragmatic hernia

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

G. Concomitant diseases

D. Severity of reflux esophagitis

• Mild form: weak symptoms, sometimes their absence (in this case, the presence of esophagitis is confirmed on the basis of X-ray data of the esophagus, esophagoscopy and targeted biopsy).
• Moderate severity: the symptoms of the disease are clearly expressed, there is a deterioration in general well-being and a decrease in work capacity.
• Severe degree: pronounced symptoms of esophagitis and the addition of complications - primarily peptic structures and cicatricial shortening of the esophagus.

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Complications and consequences

• Chronic gastritis and ulcer of the hernial part of the stomach develop with a long-standing diaphragmatic hernia. The symptoms of these complications, of course, are masked by the manifestations of the hernia itself. The diagnosis is finally verified by gastroscopy and X-ray examination of the esophagus and stomach. Kay's syndrome is known - hernia of the esophageal opening of the diaphragm, gastritis and ulcer in the part of the stomach that is in the chest cavity.
• Bleeding and anemia. Severe acute gastric bleeding is observed in 12-18%, hidden - in 22-23% of cases. Bleeding is caused by peptic ulcers, erosions of the esophagus and stomach. Chronic hidden blood loss most often leads to the development of iron deficiency anemia. Less often, _B12 -deficiency anemia develops due to atrophy of the fundus of the stomach and cessation of gastromucoprotein production.
• Incarceration of a hernia of the esophageal orifice of the diaphragm is the most serious complication. The clinical picture of incarceration of a diaphragmatic hernia has the following symptoms:
  • severe cramping pain in the epigastrium and left hypochondrium (the pain is somewhat relieved when lying on the left side);
  • nausea, vomiting with blood;
  • shortness of breath, cyanosis, tachycardia, drop in blood pressure;
  • bulging of the lower part of the chest, lagging behind when breathing;
  • a box sound or tympanitis and a sharp weakening or absence of breathing in the lower parts of the lungs on the affected side; sometimes the noise of intestinal peristalsis is determined;
  • Radiologically, it is possible to detect a shift of the mediastinum towards the healthy side.

When a 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 when passing through the esophagus.

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

Other complications of diaphragmatic hernia - retrograde prolapse of the gastric mucosa into the esophagus, intussusception of the esophagus into the hernial part are observed rarely and are diagnosed by X-ray and endoscopy of the esophagus and stomach.

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Diagnostics diaphragmatic hernia

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

X-ray diagnostics of diaphragmatic hernia

A large fixed diaphragmatic hernia has the following characteristic radiographic features:

• Before taking the contrast mass, a gas accumulation is determined in the posterior mediastinum, which is surrounded by a narrow strip of the wall of the hernial sac;
• 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.

A small axial diaphragmatic hernia is detected mainly when the patient is lying horizontally on the stomach. Its main symptoms are:

• high localization of the upper esophageal sphincter (the place where the tubular part of the esophagus passes into its ampulla);
• the location of the cardia above the esophageal opening of the diaphragm; the presence of several tortuous folds of the gastric mucosa in the supradiaphragmatic formation (the esophageal folds are narrower and there are fewer of them);
• filling of axial hernia with contrast from the esophagus.

Paraesophageal diaphragmatic hernia has the following characteristic features:

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

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FEGDS

Esophagoscopy reveals insufficiency of the cardia, the hernial cavity is clearly visible, a sign of diaphragmatic hernia is also a decrease in the distance from the anterior incisors to the cardia (less than 39-41 cm).

The mucous membrane of the esophagus is usually inflamed, there may be erosions and peptic ulcers.

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Esophagomanometry

Axial diaphragmatic hernias are characterized by the expansion of the lower zone of increased pressure above the diaphragm; the lower zone of increased pressure is displaced proximally to the esophageal opening of the diaphragm. The localization of the esophageal opening of the diaphragm is established by the phenomenon of reversal of respiratory waves, i.e. by the change in the direction of the peaks of the respiratory teeth from positive to negative (V. Kh. Vasilenko, A. L. Grebenev, 1978).

Large cardiofundal and subtotal gastric hernias 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.

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Differential diagnosis

Diaphragmatic hernia is differentiated from all diseases of the digestive organs, manifested by pain in the epigastrium and behind the breastbone, heartburn, belching, vomiting, dysphagia. Thus, diaphragmatic hernia should be differentiated from chronic gastritis, peptic ulcer, chronic pancreatitis, diseases of the large intestine, inflammatory diseases of the biliary tract. In this case, it is necessary to carefully analyze the symptoms of these diseases (they are described in the relevant chapters) and perform FGDS and X-ray of the stomach, which almost always allow you to confidently diagnose or exclude diaphragmatic hernia.

Sometimes a diaphragmatic hernia must be differentiated from relaxation or paralysis of the diaphragm (Petit's disease). When the diaphragm relaxes, its resistance decreases, and the abdominal organs shift into the chest cavity, but, unlike a diaphragmatic hernia, they are located not above, but below the diaphragm.

Relaxation of the diaphragm can be congenital or acquired, right- or left-sided, partial or complete. With diaphragmatic hernia, it is usually necessary to differentiate relaxation of the left dome of the diaphragm. In this case, the stomach and large intestine (splenic angle, sometimes part of the transverse colon) move upward, and the stomach is significantly deformed, its bending occurs, resembling a cascade stomach.

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

• a feeling of heaviness in the epigastrium after eating;
• dysphagia;
• belching;
• nausea, sometimes vomiting;
• heartburn;
• palpitations and shortness of breath;
• dry cough;
• X-ray examination reveals a persistent increase in the level of the left dome of the diaphragm. During breathing, the left dome of the diaphragm performs both normal movements (lowers on inhalation, rises on exhalation) and paradoxical movements (rises on inhalation, falls on exhalation), however, the range of motion is limited;
• darkening of the lower field of the left lung and displacement of the shadow of the heart to the right are noted;
• The gas bubble of the stomach and the splenic flexure of the colon, although displaced into the chest cavity, are located under the diaphragm.

Quite often, diaphragmatic hernia is differentiated from ischemic heart disease (in the presence of chest pain, cardiac arrhythmia). Distinctive features characteristic of ischemic heart disease (in contrast to diaphragmatic hernia) are the occurrence of pain at the height of physical or psychoemotional stress, frequent irradiation of pain to the left arm, left shoulder blade, ischemic changes on the ECG. For retrosternal pain caused by diaphragmatic hernia, its occurrence in a horizontal position, relief of pain in a vertical position and after taking alkalis, the presence of severe heartburn that occurs after eating, the absence of ischemic changes on the ECG are characteristic. However, one should not forget that a combination of ischemic heart disease and diaphragmatic hernia is possible, and that diaphragmatic hernia can cause an exacerbation of ischemic heart disease.

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Treatment diaphragmatic hernia

Asymptomatic sliding hernia of the esophageal orifice of the diaphragm (diaphragmatic hernia) does not require any specific therapy. Patients with concomitant GERD require treatment. Paraesophageal hernia of the esophagus requires surgical treatment due to the risk of strangulation.