Endoscopic signs of esophageal diaphragmatic hernia

A hernia of the esophageal opening of the diaphragm is a pathological condition caused by an intimate lesion of the muscular substrate of the diaphragm and accompanied by a transient or permanent displacement of part of the stomach into the mediastinum.

It was first described by the French surgeon Ambroise Parret in 1679 and the Italian anatomist Morgagni in 1769. In Russia, N.S. Ilshinsky in 1841 came to the conclusion that it was possible to diagnose the disease during one's lifetime. By the beginning of the 20th century, only 6 cases had been described, and from 1926 to 1938, their detection increased 32 times, and the disease took 2nd place after peptic ulcer disease. Currently, a hernia of the esophageal opening of the diaphragm is detected by X-ray examination in more than 40% of the population.

Causes of the formation of hernias of the esophageal opening of the diaphragm

Main reasons.

1. Systemic lesion of muscle tissue. The esophageal opening is formed by the diaphragm's crura, they embrace the esophagus, above and below them lies a connective tissue plate, it connects with the esophageal adventitia, forming the esophageal-diaphragmatic membrane. Normally, the opening diameter is 3.0-2.5 cm. In older people, fatty tissue accumulates here. The esophageal opening of the diaphragm expands, the membranes stretch, and dystrophy of the diaphragm's muscle fibers develops.
2. Increased intra-abdominal pressure. This contributes to prolapse of the stomach into the esophagus (during constipation, pregnancy, carrying heavy objects).

Minor causes.

1. Shortening of the esophagus. Primary shortening of the esophagus due to dysfunction of the cardia leads to reflux esophagitis, which leads to peptic stricture of the esophagus, which in turn causes shortening of the esophagus, etc. - the hernia of the esophageal opening of the diaphragm progresses.
2. Longitudinal contractions of the esophagus: can cause excitation of the vagus nerve, which in turn leads to increased longitudinal contraction of the muscles of the esophagus, opening of the cardia - a hernia of the esophageal opening of the diaphragm is formed.

The main classification of hernias of the esophageal opening of the diaphragm is the classification of Akerlund (1926). It distinguishes 3 main types of hernias:

1. Sliding hernia.
2. Paraesophageal hernia.
3. Short esophagus.

Sliding (axial) hernia occurs in almost 90% of patients with hernias of the esophageal opening. In this case, the cardiac part of the stomach is displaced into the mediastinum.

Paraesophageal hernia occurs in approximately 5% of patients. It is characterized by the fact that the cardia does not change its position, and the fundus and greater curvature of the stomach come out through the widened opening. The hernial sac may also contain other organs, such as the transverse colon.

A short esophagus as an independent disease is rare. It is a developmental anomaly and is currently not considered a hernia of the esophageal opening of the diaphragm by many specialists.

Endoscopic signs of diaphragmatic hernia

1. Reducing the distance from the anterior incisors to the cardia.
2. Gaping of the cardia or its incomplete closure.
3. Prolapse of the gastric mucosa into the esophagus.
4. The presence of a “second entrance” to the stomach.
5. Presence of a hernial cavity.
6. Gastroesophageal reflux of gastric contents.
7. Signs of reflux esophagitis and gastritis.

A decrease in the distance from the anterior incisors to the cardia. Normally, this distance is 40 cm. The cardia rosette is normally closed, with the dentate line (Z-line) located 2-3 cm above it. In axial hernias of the esophageal orifice of the diaphragm, the Z-line is determined in the thoracic section of the esophagus above the diaphragmatic orifice. The distance to it from the incisors is shortened. A diagnostic error is often made with a short esophagus. It is important to know that only the dentate line is displaced, while the cardia remains in place. The cardia rosette is often displaced to the side with hernias.

Gaping of the cardia or its incomplete closure. Also observed with axial hernias. Normally, the cardia is closed. Gaping of the cardia with hernias of the esophageal opening of the diaphragm is observed in 10-80% of cases. The esophagus must be carefully examined at the entrance, and when approaching the cardia, the air supply must be stopped, otherwise there will be errors. When passing the endoscope through the cardia, there is no resistance, and normally there is insignificant resistance.

Prolapse of the gastric mucosa into the esophagus is a characteristic endoscopic sign of axial hernia. The typical dome-shaped protrusion of the gastric mucosa above the diaphragmatic opening is best determined by deep inspiration. The gastric mucosa is mobile, while the esophageal mucosa is fixed. Examine at the entrance in a calm state, since when the device is removed, a gag reflex occurs and the prolapse of the mucosa may be normal. The height can increase up to 10 cm.

The presence of a "second entrance" to the stomach. Characteristic of paraesophageal hernia. The first entrance is in the area of the gastric mucosa, the second - in the area of the esophageal opening of the diaphragm. With deep breathing, the legs of the diaphragm converge and diagnostics are simplified.

The presence of a hernial cavity is a characteristic sign of a paraesophageal hernia. It is determined only by examination from the stomach cavity. It is located next to the opening of the esophagus.

Gastroesophageal reflux of gastric contents is clearly visible on the left side.

Since the locking function of the cardia is not impaired in paraesophageal hernias, the last two signs are not characteristic of these hernias and are observed mainly in sliding hernias.

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