Endoscopic signs of hernia of the esophageal opening of the diaphragm

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 temporary or permanent displacement of part of the stomach into the mediastinum.

For the first time described the French surgeon Ambroise Parre in 1679 and the Italian anatomist Morgagni in 1769. In Russia, NS Ilshinskiy. In 1841 came to the conclusion about the possibility of intravital diagnosis of the disease. By the beginning of the 20th century, only 6 cases had been described, and from 1926 to 1938, their detection increased by 32 times, and the disease took 2nd place after a peptic ulcer. At present, hernia of the esophageal opening of the diaphragm is detected in x-ray examination in more than 40% of the population.

The causes of the formation of hernia of the esophageal aperture of the diaphragm

Main reasons.

1. Systemic damage to muscle tissue. The esophagus is formed by the feet of the diaphragm, they cover the esophagus, a connective tissue plate lies above and below them, it joins with the esophagus adventitia, forming the esophageal-diaphragm membrane. Normally, the diameter of the hole is 3.0-2.5 cm. In older people, fatty tissue accumulates here. The esophagus of the diaphragm expands, the membranes are stretched, the degeneration of the muscular fibers of the diaphragm develops.
2. Increased intra-abdominal pressure. This contributes to the prolapse of the stomach into the esophagus (with constipation, pregnancy, weight-bearing).

Non-primary reasons.

1. Shortening of the esophagus. Primary shortening of the esophagus in violation of the cardia function leads to reflux-esophagitis, which leads to peptic stricture of the esophagus, and this, in turn, causes shortening of the esophagus, etc. - hernia of the esophageal opening of the diaphragm progresses.
2. Longitudinal contractions of the esophagus: may 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 aperture of the diaphragm is formed.

The main classification of hernia of the esophageal aperture of the diaphragm is the classification of Akerlund (1926). There are 3 main types of hernia:

1. Sliding hernia.
2. The parasophageal hernia.
3. Short esophagus.

Sliding (axial) hernia occurs in almost 90% of patients with hiatal hernia. In this case, the cardiac region of the stomach is shifted to the mediastinum.

A parasophageal hernia occurs in approximately 5% of patients. Characterized by the fact that the cardia does not change its position, and through the dilated aperture the bottom and the greater curvature of the stomach come out. The hernial sac may also contain other organs, for example, the transverse colon.

A short esophagus as an independent disease is rare. It is an anomaly of development and many specialists as a hernia of the esophageal aperture are not currently considered.

Endoscopic signs of diaphragmatic hernia

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

Reducing the distance from the front incisors to the cardia. Normally, this distance is 40 cm. The cardia socket is normally closed, in 2-3 cm above it is a dentate line (Z-line). With the axial hernia of the esophageal opening of the diaphragm, the Z-line is defined in the thoracic esophagus above the diaphragmatic opening. Distance to it from the cutters is shortened. A diagnostic error is often tolerated in the short esophagus. It is necessary to know that when it is shifted only the dentate line, and the cardia is in place. Often the rosette of the cardia is displaced with hernias to the side.

Ziya cardia or incomplete its closure. It is also observed with axial hernias. Normally, the cardia is closed. Ziya cardia with hernias of the esophageal aperture of the diaphragm is observed in 10-80% of cases. Esophagus when viewed at the entrance should be inspected carefully, and when approaching the cardia, the air supply should be stopped, otherwise there will be errors. When the endoscope passes through the cardia, there is no resistance, and there is little resistance in the norm.

The prolapse of the gastric mucosa in the esophagus is a characteristic endoscopic sign of axial hernia. A typical domed bulging of the gastric mucosa above the diaphragmatic opening is best determined by deep inspiration. The gastric mucosa is mobile, while the esophagus is fixed. Inspect at the entrance in a calm state, tk. When removing the device there is a vomiting reflex and prolapse of the mucosa may be normal. The height can be increased up to 10 cm.

The presence of a "second entrance" in the stomach. Characteristic for paraezophageal hernia. The first entry in the area of the stomach mucosa, the second - in the area of the esophageal opening of the diaphragm. With deep breathing, the diaphragm's legs converge and the diagnosis is simplified.

The presence of the hernial cavity is a characteristic feature of the paresisophageal hernia. It is determined only when viewed from the side of 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 blocking function of the cardia during paraesophageal hernia is not disturbed, the last two signs for these hernias are not characteristic and are observed, mainly, with sliding hernias.

[1], [2], [3], [4], [5], [6], [7], [8], [9]