All about diaphragmatic hernias and their treatment. Diaphragmatic hernia: types, symptoms, treatment

Diaphragmatic hernia develops when a pathological opening appears in the anatomical septum connecting two sections (thoracic and abdominal), through which the organs of the chest part enter the abdominal part and vice versa. In the middle, the diaphragm consists of connective tissue, and it is usually in it that a defect is formed, called a diaphragmatic hernia.

Varieties

In modern medical practice, there are several varieties of this pathological condition. More often than others, congenital diaphragmatic hernia develops in newborn children. It is associated with anomalies in the development of the fetus in the womb.

The second type of this pathology is neuropathic hernia, which occurs as a result of insufficient diaphragm tone. With such a pathology, a certain section of the diaphragm relaxes, which leads to its stretching, and subsequently to rupture with the formation of a hernia.

The third variety is traumatic diaphragmatic hernia in children and adults. Such a pathology can be true and false, and it is associated with injuries that led to the formation of a hole in the anatomical septum. They speak of a true anomaly when organs are located in the hernial sac in the region of the pathological diaphragmatic opening, and false when it is absent.

And finally, the last variety is a hernia of the natural diaphragmatic opening. If stretching of tissues is observed in the region of the natural opening for the esophagus, a hernia of the esophagus or diaphragm may occur.

Causes

Since there are several types of pathologies in the area of ​​the anatomical septum, the reasons for the development of such a pathological condition are different. If we talk about a congenital anatomical defect in the diaphragm of children, then it occurs due to genetic abnormalities in the fetus, and scientists cannot exactly determine the reason why such a defect occurs. Also, in older children, diaphragmatic hernia may appear as a result of nervous disorders or as a result of certain chronic diseases, for example, and other pathologies.

If we talk about the development of the disease in adults, it should be noted that the hernia of the diaphragm leads to:

• traumatic injuries (blunt abdominal trauma, chest bruises, stab wounds, etc.);
• violation of innervation due to problems with the nervous system;
• conditions leading to a long-term increase in pressure in the abdominal cavity - prolonged childbirth, chronic, heavy lifting, prolonged and debilitating cough, and some others;
• violations of the tone of the anatomical septum, resulting from age-related changes in the body, which manifest themselves in people after 50 years;
• chronic diseases of the digestive tract (peptic ulcer, and others).

Note that this pathology occurs more often in children than in adults. Moreover, we are talking about both a congenital anomaly that develops in the fetus and leads to compression of the lungs and heart of the child, and an acquired one that occurs due to the anatomical weakness of the diaphragm. The development of a violation in the fetus occurs as a result of an unfavorable course of pregnancy. For example, if a woman smokes or drinks alcohol while pregnant, or if she takes certain medications, is exposed to radiation, lives in an area with unfavorable environmental conditions, or works in hazardous industries.

As mentioned above, in children, the diaphragm is weaker than in adults, so hernias develop several times more often in them. And in order to prevent the appearance of such a defect, parents should protect children from excessive physical exertion and heavy lifting, from injuries and the development of constipation, and also treat respiratory diseases in a timely manner, preventing the appearance of a prolonged cough.

Symptoms

The symptoms of this pathological condition depend on the location of the hole in the diaphragm. But often such symptoms are not specific, and may indicate problems with the organs of the digestive tract located in the chest region - be associated with diseases of the esophagus, stomach or duodenum. Moreover, if the hernia is small, there may be no symptoms at all - they appear only when it increases.

The first symptoms that the patient complains about are:

• constant, which does not go away even when taking antacids, and intensifies if you tilt the torso forward;
• belching air.

These symptoms are associated with malfunctions of the esophageal valve, which leads to the penetration of air into the stomach, as well as the penetration of gastric contents into the esophagus.

Other symptoms that occur with a hernia of the esophagus or diaphragmatic opening are:

• pain in the chest area, which may occur due to compression of the organs located in the hernial sac;
• cough not associated with colds;
• increased heart rate that occurs after eating;
• burning sensation behind the sternum;
• bloating and pain in the abdomen, resulting from air entering the intestine due to pathological changes in the anatomical septum.

In cases where pinching occurs in the esophagus, bleeding may occur, which leads to the development of the patient. If there is an infringement of a hernia, symptoms such as:

• nausea;
• increase in body temperature;
• severe pain in the left side of the chest.

Note that patients often take the symptoms of diaphragmatic hernia for symptoms of other diseases, such as pathologies of the cardiovascular system or diseases of the gastrointestinal tract. Therefore, it is very important to diagnose the disease in a timely manner and prescribe treatment in order to avoid the development of severe complications.

Diagnosis and features of therapy

Violations in the fetus can be diagnosed even in the womb, during an ultrasound examination. In children, diagnosis involves an X-ray study with contrast, which allows you to see the protrusion of the esophagus or stomach through the hernial sac. In adults, diagnosis can be made using radiography and other methods, such as fibroesophagogastroduodenoscopy (FEGDS). In addition, the acidity of the stomach and esophagus is examined, and its elevated values ​​give the doctor the opportunity to suspect this pathology.

Such a disease can be treated conservatively and surgically. The main method is the surgical removal of a hernia, however, after such treatment, in 4 out of 10 cases, the disease reappears. Surgical treatment consists of several types of operations:

• suturing the fundus of the stomach to the wall of the esophagus;
• suturing the hole and strengthening it with a special mesh (this is the method used in children);
• fixation of the stomach to the anterior abdominal wall (after its reduction).

Unfortunately, if the pathology is treated conservatively, it is impossible to cure the patient - you can only reduce the manifestations, so conservative therapy is suitable in cases where the hernia is small, or it is used to prevent the recurrence of the pathology after surgical treatment.

The treatment of diaphragmatic hernia consists in proper nutrition and adherence to the daily regimen, as well as in taking medications to reduce acidity, eliminate constipation, get rid of ulcers, etc. Sometimes patients believe that they can cure a hernia with folk remedies. In fact, folk remedies can only alleviate the patient's condition, as well as with the help of conservative therapy. That is, the treatment of folk remedies for this pathology is aimed at eliminating belching, heartburn, constipation. So, the best folk remedies for heartburn are decoctions and infusions, in which such herbs as chamomile, celandine, marshmallow root, plantain are used. Peppermint and fennel fruits are good for bloating.

A hiatal hernia (diaphragmatic hernia) is a congenital or acquired defect in the muscular septum that separates the chest cavity from the abdominal cavity. Various negative factors during the fetal development of the fetus or already in an adult lead to weakness of certain sections of the diaphragm, from which the physiological opening (esophageal) expands and passes through itself not only the abdominal part of the esophagus, but also the cardial part of the stomach (in advanced cases, the entire organ) . Such an anomaly is often found in premature babies, which is associated with insufficient development of muscle tissue or the appearance of a defect during pregnancy. In adult patients, the disease is associated with high loads, poor lifestyle and excess weight.

There are many risk factors, and if there is a predisposition to this disease, then any systemic ailment, increased load, cough can provoke a pathological violation of the position of the abdominal and thoracic organs. You can observe the symptoms of a diaphragmatic hernia from the first stage, if you pay attention to minor changes in the body, such as discomfort in the chest, hiccups, heaviness after eating, the appearance of pain while bending the torso forward.

Diaphragmatic hernia or HH is a chronic disease associated with the mixing of the organs of the abdominal cavity through the diaphragm. Displaced organs begin to compress the lungs and heart, because as soon as it is possible to determine the disease, conservative or less often surgical treatment begins.

Specific symptoms of HH

A hernia may be asymptomatic, but this is not quite the right definition. Any disease has its manifestations, but a person does not attach importance to them. Such mild symptoms include deterioration of health, heaviness after eating, belching, heartburn. These symptoms can go separately or in combination, but they gradually increase, and the disease itself progresses, as it proceeds in four stages.

In 97% of patients with a hernia of the POD, reflux is manifested (reverse reflux of food from the stomach into the esophagus), and this pathology most often allows you to determine the diaphragm defect, as it has severe symptoms.

The severity of manifestations also depends on the form of the hernia. In the case of a paraesophageal hernia, symptoms may indeed be absent, but for a short time, moreover, such hernias are most often infringed and lead to serious consequences.

For any type of hernia POD:

1. Pain - localized in the stomach, radiates to the back, sometimes has a surrounding character, which leads to an incorrect preliminary diagnosis;
2. Reflux esophagitis - with diaphragmatic hernia, reflux disease occurs, causing pain, belching, regurgitation, dysphagia;
3. Disorders of the digestive tract - there is bloating, nausea, vomiting, constipation.

Features of pain in diaphragmatic hernia

Differential diagnosis of diaphragmatic hernia necessarily includes heart disease, because there are cases when HH occurs together with coronary disease, given the incidence among the elderly.

About 30% of patients complain of pain in the heart, which is taken for angina pectoris and even myocardial microinfarction.

During the diagnosis, the following factors are taken into account:

1. Time of onset of pain: with a diaphragmatic hernia, pain in the stomach and chest appears mainly after eating, during exercise, when the body is tired, sneezing, coughing, bloating;
2. The subsidence of pain occurs after belching, deep inspiration, with the vertical position of the body, after a glass of alkaline water;
3. With a hernia, acute pains are extremely rare, they are rather dull, moderate and have a temporary pattern;
4. Bending forward is accompanied by pain.

What causes pain in diaphragmatic hernia?

1. When the stomach passes into the chest cavity, its nerve endings of the fundus and cardia are compressed;
2. Increased acidity of gastric juice and irritation of the esophagus with reflux;
3. Spasms and hypermotor dyskinesia of the esophagus;
4. In gastroesophageal reflux, the walls of the esophagus stretch.

Reflux esophagitis and hernia

Most of the symptoms are associated with reflux, which indicates the weakness of the gastric sphincter and the need for surgical treatment to eliminate the defect.

Gastroesophageal reflux in HH shows the following symptoms:

1. Swallowing disorder or dysphagia is a temporary symptom that appears suddenly and disappears for a while. This phenomenon is more often observed when taking liquid and soft foods. This is due to psychological trauma, when eating is accompanied by pain. Treatment includes a course of psychotherapy, since the traumatic factor remains the main one. As soon as it becomes a permanent symptom, it is necessary to conduct a differential diagnosis with esophageal cancer, peptic ulcer;
2. Belching, regurgitation (regurgitation) - appears after eating, at night, when a person lies down after eating. Constant burping and spitting up can lead to pneumonia. Treatment is carried out with medication and diet, it is necessary to reduce the acidity of gastric juice;
3. Dental diseases and burning of the tongue are caused by the acidic contents of the stomach entering the oral cavity, which causes a burn of the mucous membrane. Hydrochloric acid vapor, in turn, adversely affects the enamel, corroding it (the process of decalcification), which leads to increased sensitivity and the appearance of stains on the teeth. Treatment at the dentist does not give any results while the underlying disease is present.

Running esophagitis leads to erosions and ulcers of the esophagus, which is especially dangerous for patients with a predisposition to oncology.

Conservative treatment

Non-surgical treatment of a subcutaneous hernia includes the following medications:

1. Maalox is an antacid used to coat the gastric mucosa and neutralize hydrochloric acid. Treatment with this drug allows you to eliminate bloating, normalize digestion;
2. Almagel Neo - antacid, absorbs harmful elements, reduces the aggressiveness of hydrochloric acid and reduces bloating;
3. Gastal is a combined agent that neutralizes hydrochloric acid. Treatment eliminates belching, reduces pain. The drug has a prolonged action;
4. Phosphalugel is an antacid agent that has an adsorbing, enveloping effect. Treatment is carried out in order to neutralize hydrochloric acid and eliminate the symptomatic complex.

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

ICD-10 code

K44 Diaphragmatic hernia

Epidemiology

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

Causes of diaphragmatic hernia

The cause of a diaphragmatic hernia is unknown, but a hiatal hernia is thought to be caused by stretching of the fascial ligaments between the esophagus and the diaphragmatic fissure (the opening of the diaphragm through which the esophagus passes). With a sliding hiatal hernia, the most common type is the exit of the gastroesophageal junction and part of the stomach above the diaphragm. In a paraesophageal hiatal hernia, the gastroesophageal junction is in a normal position, but part of the stomach is adjacent to the esophagus. Hernias may also exit through other diaphragmatic defects.

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

Pathogenesis

As you know, the esophagus passes through the esophageal opening of the diaphragm before entering the cardia of the stomach. The esophageal opening of the diaphragm and the esophagus are connected by a very thin connective tissue membrane, which hermetically delimits the abdominal cavity from the chest. The pressure in the abdominal cavity is higher than in the chest, therefore, under certain additional conditions, this membrane is stretched, and the abdominal part of the esophagus with part of the cardial part 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 connective tissue structures that strengthen the esophagus in the opening of the diaphragm;
• increased intra-abdominal pressure;
• upward traction of the esophagus in dyskinesias of the digestive tract and diseases of the esophagus.

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

Weakness of the ligamentous apparatus and tissues of the esophageal opening of the diaphragm develops with an increase in the age of a person due to involutive processes, therefore, a hernia of the esophageal opening of the diaphragm (diaphragmatic hernia) is observed mainly in patients older than 60 years. In the connective tissue structures that strengthen the esophagus in the opening of the diaphragm, dystrophic changes occur, they lose elasticity, atrophy. The same situation can develop in untrained, asthenic people, as well as in people with congenital weakness of connective tissue structures (for example, flat feet, Marfan's 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 a “hernial gate” is formed, through which the abdominal esophagus or the adjacent part of the stomach can penetrate into the chest cavity.

Increased intra-abdominal pressure

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

An increase in intra-abdominal pressure is observed with pronounced flatulence, pregnancy, indomitable vomiting, severe and persistent cough (with chronic non-specific lung diseases), ascites, in the presence of large tumors in the abdominal cavity, with a sharp and prolonged tension of the muscles of the anterior abdominal wall, severe degrees of obesity.

Among these causes, a 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.

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

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

known triad of Castaing(hiatal hernia, chronic cholecystitis, duodenal ulcer) and Saint's triad(hernia of the esophageal opening of the diaphragm, chronic cholecystitis, diverticulum of the large intestine).

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 its traction upwards (“pulling up” into the chest cavity).

In the process of development of a hernia of the esophageal opening of the diaphragm, a sequence of penetration into the chest cavity of various sections of the esophagus and stomach is noted - 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 opening 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 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, consequently, gastroesophageal reflux and reflux esophagitis.

Diaphragmatic hernia symptoms

Most patients with a sliding hiatal hernia are asymptomatic, but chest pain and other signs of reflux may be present. Paraesophageal hiatal hernia is generally asymptomatic, but unlike a sliding hiatal hernia, it can be strangulated and complicated by strangulation. Hidden or massive gastrointestinal bleeding can complicate any type of hernia.

Diaphragmatic hernia in 50% of cases can be hidden or with very minor symptoms and simply be an accidental finding on x-ray or endoscopic examination of the esophagus and stomach. Quite often (in 30-35% of patients), cardiac arrhythmias (extrasystole, paroxysmal tachycardia) or pain in the heart area (non-coronary cardialgia) come to the fore in the clinical picture, which causes diagnostic errors and unsuccessful treatment by a cardiologist.

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

Pain

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

Approximately 15-20% of patients have pain localized in the region of the heart and is mistaken for angina pectoris or even myocardial infarction. It should also be taken into account that a combination of diaphragmatic hernia and coronary artery disease is possible, especially since diaphragmatic hernia often occurs in the elderly, which is also characterized by coronary artery disease.

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

• pains most often appear after eating, especially plentiful, during physical exertion, lifting weights, coughing, flatulence, in a horizontal position;
• pain disappears or decreases after belching, vomiting, after a deep breath, moving to a vertical position, as well as taking alkalis, water;
• the pains are rarely extremely severe; most often they are moderate, dull
• the pain is aggravated by bending 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 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 walls of the esophagus with gastroesophageal reflux;
• hypermotor dyskinesia of the esophagus, development of cardiospasm;
• in some cases, pylorospasm develops.

In the case of complications, the nature of pain in diaphragmatic hernia changes. For example, during the development solarite pains in the epigastrium become persistent, intense, acquire a burning character, increase with pressure on the solar plexus projection area, weaken 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 pains become dull, aching, constant, they are localized high in the epigastrium and the region of the xiphoid process of the sternum.

At infringement the hernial sac in the hernial orifice is characterized by constant intense pain behind the sternum, sometimes of a tingling nature, radiating to the interscapular region.

Cardia failure, gastroesophageal reflux, reflux esophagitis

With a diaphragmatic hernia, gastroesophageal reflux disease naturally develops.

This group includes the following symptoms of diaphragmatic hernia:

• eructation of sour gastric contents, often with an admixture of bile, which creates a taste of bitterness in the mouth. Possible belching of air. Eructation occurs shortly after eating and is often very pronounced. According to V. X. Vasilenko and A. L. Grebenev (1978), the severity of belching depends on the type of diaphragmatic hernia. With cardiofundal fixed hernia, belching is very pronounced. With non-fixed cardiofundal or fixed cardiac diaphragmatic hernia, belching is less pronounced;
• regurgitation (regurgitation) - appears after eating, usually in a horizontal position, often at night ("wet pillow symptom"). Most often, regurgitation occurs with recently taken food or acidic stomach contents. Sometimes the volume of regurgitated masses is large enough and can lead to the development of aspiration pneumonia. Regurgitation is most characteristic of cardiofundal and cardiac diaphragmatic hernias. Regurgitation is due to the esophagus's own contractions and is not preceded by nausea. Sometimes regurgitated contents are chewed and swallowed again;
• dysphagia is difficulty in passing food through the esophagus. Dysphagia is not a permanent symptom, it can come and go. A characteristic of diaphragmatic hernia is that dysphagia is most often observed when eating liquid or semi-liquid food and is provoked by taking 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 carried out, as well as complications of a diaphragmatic hernia (strangulated hernia, development of a peptic ulcer of the esophagus, esophageal stricture) should be suspected;
• retrosternal pain when swallowing food - appears when a diaphragmatic hernia is complicated by reflux esophagitis; as the esophagitis stops, the pain decreases;
• heartburn is one of the most common symptoms of diaphragmatic hernia, especially axial hernia. 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 with axial hernias. A characteristic feature of hiccups is its 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 infrequent symptom with diaphragmatic hernia, may be due to 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 pathology of the respiratory organs - tracheobronchitis, obstructive bronchitis, attacks of bronchial asthma, aspiration pneumonia (bronchoesophageal syndrome). Among these manifestations, aspiration of gastric contents into the respiratory tract is especially important. As a rule, this is observed at night, during sleep, if shortly before sleep the patient had a hearty dinner. There is an attack of persistent cough, often it is accompanied by suffocation and pain behind the sternum.

Objective examination of the patient

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

Anemia 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 occult bleeding from the lower esophagus and stomach due to reflux esophagitis, erosive gastritis, and sometimes peptic ulcers of the lower esophagus. Anemia is iron deficiency and is manifested by all the symptoms characteristic of it. . The most significant clinical signs of iron deficiency anemia: weakness, dizziness, darkening of the eyes, pallor of the skin and visible mucous membranes, sideropenia syndrome (dry skin, trophic changes in the nails, perversion of taste, smell), low iron in the blood, hypochromia of erythrocytes, anisocytosis, poikilocytosis , decrease in hemoglobin and red blood cells, low color index.

Forms

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

Classification based on anatomical features

There are the following three options:

1. Sliding (axial, 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 enter the chest cavity through the expanded esophageal opening of the diaphragm and return back to the abdominal cavity (when the patient changes position).
2. Paraesophageal hernia. With this option, 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 esophagus (paraesophageal).
3. Mixed variant of hernia. With a mixed version of diaphragmatic hernia, a combination of axial and paraesophageal hernias is observed.

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 1st degree - in the chest cavity (above the diaphragm) is the abdominal esophagus, and the cardia is at the level of the diaphragm, the stomach is elevated and directly adjacent to the diaphragm.
• Diaphragmatic hernia II degree - in the chest cavity is located the abdominal part of the esophagus, and directly in the area of ​​the esophageal opening of the diaphragm - already 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).

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);
• hernias of another type (intestinal, omental, etc.).

B. Complications of diaphragmatic hernia

1. Reflux esophagitis
   1. morphological characteristic - 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) bleeding
3. Retrograde prolapse of the gastric mucosa into the esophagus
4. Invagination of the esophagus into the hernial part
5. Esophageal perforation
6. Reflex angina
7. Incarcerated hernia (for 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. The mechanism of hernia occurrence: pulsion, traction, mixed.

D. Concomitant diseases

D. Severity of reflux esophagitis

• Mild form: mild symptoms, sometimes their absence (in this case, the presence of esophagitis is ascertained 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 working capacity.
• Severe degree: severe symptoms of esophagitis and the addition of complications - primarily peptic structures and cicatricial shortening of the esophagus.

Complications and consequences

• Chronic gastritis and ulcer 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. The final diagnosis is verified using gastroscopy and fluoroscopy of the esophagus and stomach. Kay's syndrome is known - a hernia of the esophageal opening of the diaphragm, gastritis and an ulcer in that part of the stomach that is located in the chest cavity.
• Bleeding and anemia. Severe acute 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 occult blood loss leads to the development of most often iron deficiency anemia. Less commonly, B 12 deficiency anemia develops due to atrophy of the fundus of the stomach and the cessation of gastromucoprotein production.
• Infringement of a hernia of the esophageal opening of the diaphragm is the most serious complication. The clinical picture of infringement of diaphragmatic hernia has the following symptoms:
  • severe cramping pain in the epigastrium and left hypochondrium (the pain is somewhat weakened in the position on the left side);
  • nausea, vomiting with an admixture of blood;
  • shortness of breath, cyanosis, tachycardia, drop in blood pressure;
  • bulging of the lower part of the chest, lagging behind when breathing;
  • box sound or tympanitis and a sharp weakening or absence of breathing in the lower parts of the lungs on the side of the lesion; sometimes the noise of intestinal motility is determined;
  • X-ray can detect mediastinal shift to the healthy side.

When a paraesophageal hernia is infringed, Borri's syndrome develops - a tympanic shade of sound during percussion of the paravertebral space on the left at the level of the thoracic vertebrae, shortness of breath, dysphagia, contrast delay when passing through the esophagus.

• Reflux esophagitis is a natural and frequent 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 rare and are diagnosed during fluoroscopy and endoscopy of the esophagus and stomach.

Diagnosis of diaphragmatic hernia

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

X-ray diagnosis of diaphragmatic hernia

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

• before receiving a contrast mass in the posterior mediastinum, an accumulation of gas is determined, 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.

Small axial diaphragmatic hernia is detected mainly in the horizontal position of the patient 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 their number is less);
• filling of the axial hernia with contrast from the esophagus.

Paraesophageal diaphragmatic hernia has the following characteristic features:

• the esophagus is well filled with a 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;
• barium suspension from the stomach enters the hernia (part of the stomach), i.e. from the abdominal cavity to the chest, this is clearly visible in the vertical and especially in the horizontal position of the patient;
• when the fundal paraesophageal hernia is infringed, the gas bubble in the mediastinum increases sharply, against its background, a horizontal level of the liquid contents of the hernia appears.

FEGDS

With esophagoscopy, cardia insufficiency is determined, 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 erosion, peptic ulcer.

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 proximal to the esophageal opening of the diaphragm. The localization of the esophageal opening of the diaphragm is determined by the phenomenon of reversal of respiratory waves, i.e. by changing the direction of the peaks of the respiratory teeth from positive to negative (V. Kh. Vasilenko, A. L. Grebenev, 1978).

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

Relaxation of the diaphragm is congenital and acquired, right- and left-sided, partial and complete. With a diaphragmatic hernia, it is usually necessary to differentiate the relaxation of the left dome of the diaphragm. At the same time, the stomach and large intestine (splenic angle, sometimes part of the transverse colon) move upward, and the stomach is significantly deformed, its inflection occurs, 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 determined a persistent increase in the level of the location of the left dome of the diaphragm. When breathing, the left dome of the diaphragm performs both normal movements (falls on inspiration, rises on exhalation) and paradoxical movements (rises on inspiration, falls on expiration), however, the range of motion is limited;
• there is a darkening of the lower field of the left lung and a shift in the shadow of the heart to the right;
• the gas bladder 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 ischemiachesky heart disease(in the presence of retrosternal pain, cardiac arrhythmias). Distinctive features characteristic of IHD (unlike 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 shoulder blade, ischemic changes on the ECG. Retrosternal pain caused by diaphragmatic hernia is characterized by its appearance in a horizontal position, relief of pain in a vertical position and after taking alkalis, the presence of severe heartburn that occurs after eating, and the absence of ischemic changes on the ECG. However, we should not forget that a combination of coronary artery disease and diaphragmatic hernia is possible, and that diaphragmatic hernia can exacerbate coronary artery disease.

Diaphragmatic hernia treatment

An asymptomatic sliding hiatal hernia (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.

Diaphragmatic hernia occurs in 0.5% of the world's population. In half of the cases, it does not manifest itself during life, and therefore patients learn about its presence only at an examination prescribed due to other pathologies. In the absence of treatment, the likelihood of complications is high, and therefore everyone should know about the specific symptoms and prerequisites for the development of the disease.

Diaphragmatic hernia (DH) is a protrusion of the abdominal organs into the chest, resulting from a violation of the integrity of the diaphragm. At the same time, patients experience pain in the stomach, shortness of breath and a general deterioration in well-being.

When protrusion, the normal movement of food masses through the organs of the gastrointestinal tract is disrupted. This can cause the development of congestion, ulcers and erosion.

The diaphragm performs several important functions in the human body:

• separates the abdominal and chest cavities, protecting the lungs from squeezing;
• participates in the process of breathing, allowing the lungs to open better when inhaling;
• regulates pressure in the thoracic and abdominal cavities.

It is a flat muscle that is attached to the walls of the chest. The diaphragm has openings for the esophagus and inferior vena cava. Most often (about 90% of cases) a hernia occurs at the site of the esophagus. There are cases when a hernia occurred in the middle of the muscle itself.

Causes

Among the most popular reasons for the development of a hernia, I highlight the following:

• developmental pathologies that occur in the prenatal period of life;
• traumatic injuries of the abdominal cavity or chest;
• a strong increase in intra-abdominal pressure: frequent constipation, coughing, frequent childbirth;

  

• deterioration of muscle innervation;
• increased elasticity of the esophageal sphincter;
• pathology of the gastrointestinal tract - inflammation of the esophagus, ulcerative lesions, pancreatitis;
• advanced age over 60 years;

  

• hard physical work;
• regular weight lifting;

  

• frequent overeating;
• hormonal disorders.

These factors create favorable conditions for the formation of a hernia in the diaphragm. With the combined effect of several of them, the likelihood of developing disorders increases.

Hernia types

The classification of protrusions was proposed by B.V. Petrovsky. It is based on the cause of occurrence and distinguishes two main types: traumatic and non-traumatic.

Traumatic hernias, in turn, are divided into:

• true (due to closed injuries);
• false (due to injuries).

Non-traumatic hernias are of the following types:

• congenital false;
• true weakened areas of the diaphragm;
• true atypical location;
• physiological openings of the diaphragm.

Hiatus hernia (HH) occurs in more than 90% of cases. With such a violation, protrusion of the coronary part of the stomach most often occurs. Less often, the intestines protrude.

Symptoms

A protrusion in the diaphragm area is characterized by specific symptoms. But the degree of manifestation of these signs is so small that patients often ignore them, causing their appearance by other reasons. In half of the cases, DG does not manifest itself at all. A pronounced symptomatology occurs only in cases where the hernial sac is large.

Symptoms in children

In childhood, congenital DH is more common. At the same time, the following symptoms appear in babies:

• pallor of the skin, up to their blue;

  

• shortness of breath after feeding;
• frequent regurgitation of large amounts of food;

  

• vomit;
• bad sleep;
• irritability.

  

Signs in adults

In adults, DG is found much more often than in children. The reason for this may be the complex effect of provoking factors on the body throughout life. The most common signs of DG in adults include:

• retrosternal pain resulting from squeezing organs;
• the appearance of heartburn, which is aggravated by bending forward and after meals;

  

• frequent belching with air content;
• bloating;

  

• breathing difficulties.

If left untreated, the disease can worsen. In this case, there is a high probability of developing esophagitis or bleeding from perforation of the hernial sac.



Esophagitis is a disease of the esophagus, accompanied by inflammation of its mucous membrane

Signs of acute DG include:

• acute pain in the stomach;
• nausea and vomiting;
• stool retention;
• deterioration in general well-being.



Nausea and acute pain in the stomach area - symptoms of a hernia

Such symptoms indicate severe damage and require immediate medical attention. In the absence of medical care, the likelihood of developing peritonitis is high.

Diagnostic methods

As mentioned above, DG is most often found in patients during examination, and they themselves may not even be aware of its presence. There are two main types of diagnostics that allow you to confirm the diagnosis.

Radiography of the stomach



The principle of operation of this technique is the deposition of a contrast agent on the walls of the stomach. For this purpose, the patient on an empty stomach is given a special barium suspension. It tastes like chalk. The patient drinks the suspension and after 1-1.5 hours will be ready to perform the study.



The x-ray shows the shape of the stomach and the presence of hernial sacs. Suspension is naturally washed out of the stomach with further food. It does not have any negative effect on the body and does not cause inconvenience. Therefore, this method is often used to diagnose DG in children.



The most informative diagnostic method. This is an invasive technique, during which the doctor can not only check for bags and protrusions, but also assess the condition of the walls. This technique is relevant for checking for the presence of ulcerative and erosive lesions.



FGDS is performed on an empty stomach, no preliminary preparation for analysis is required. The patient is injected into the stomach with a special probe, which is equipped with a camera. With the help of air flow, the walls of the stomach are cleansed of juice and food debris. The use of FGDS, despite its informativeness, is a rather unpleasant procedure, and therefore it is prescribed mainly for adults.



Methods of treatment

Therapy depends on the condition of the patient. In non-acute cases, treatment is symptomatic. It includes taking medications. Their list is presented in the table.



"Platifillin"



"Drotaverine"



Additionally, the diet is adjusted. Meals should be at least 4 times a day. Reduced portion sizes are required to reduce stomach strain. Foods that can cause irritation of the gastric mucosa and stimulate the release of bile are completely excluded from the diet: fried, fatty, salty, smoked, spicy foods.

Surgery is performed in acute conditions:

• large size of the hernial sac;
• infringement of internal organs;
• failure to respond to standard treatment.

Emergency surgical intervention is performed in case of bleeding, perforation of the ulcer, perforation of the hernial sac. Surgical treatment consists in excision of the sac, elimination of the hernial opening. If there are perforations in the diaphragm itself, it is possible to apply special surgical patches made of artificial material.



Diaphragmatic hernia, while minimizing the impact of provoking factors, does not pose a threat to the patient's life. But such patients require regular examinations in order to exclude exacerbations.

Video - Laparoscopic treatment of diaphragmatic hernia of the esophagus

A diaphragmatic hernia is a protrusion of the esophagus and/or upper stomach through the esophageal opening of the diaphragm. The main causes of diaphragmatic hernia are: pregnancy, difficult childbirth, chronic constipation, chronic respiratory diseases accompanied by cough, hard physical labor. The main symptom of a diaphragmatic hernia is severe and often recurring heartburn, chest pain, bouts of nocturnal choking cough.

A diaphragmatic hernia is diagnosed by a gastroenterologist or surgeon. Treatment for diaphragmatic hernia includes diet, medication for heartburn and chronic constipation, and surgery to remove the hernia.

What is diaphragm and diaphragmatic hernia?

The diaphragm is a dense muscular septum that separates the chest cavity from the abdominal cavity. The edges of the diaphragm are composed of muscles and are attached to the ribs and spine. The center of the diaphragm has practically no muscle fibers (consists of connective tissue) and protrudes towards the chest in the form of a dome.

Large vessels, nerves and the esophagus pass through the diaphragm (closer to the spine). In places where the vessels and the esophagus pass through the diaphragm, there are holes, which are the "weak points" of the diaphragm through which hernias come out.

Diaphragmatic hernias are bulges in the esophagus, stomach, or small intestine through weak points in the diaphragm. When the esophagus and the upper part of the stomach protrude through the diaphragm into the chest cavity, the work of the esophageal valve (sphincter), which closes the transition from the esophagus to the stomach, is disrupted. This fact is the cause of the vast majority of the symptoms of diaphragmatic hernia. Dysfunction of the esophageal valve results in the constant ejection of acidic stomach contents into the esophagus. The mucous membrane of the esophagus cannot withstand increased acidity, as the gastric mucosa does, and becomes inflamed (esophagitis occurs).

Causes of diaphragmatic hernia of the stomach and esophagus

The main cause of diaphragmatic hernias of the esophagus and stomach is the expansion of the opening of the diaphragm through which the esophagus passes into the abdominal cavity. In turn, the expansion of the esophageal opening of the diaphragm can be caused by the following phenomena:

1. A significant increase in pressure in the abdominal or chest cavity:

• chronic diseases accompanied by cough (50% of patients with chronic bronchitis have diaphragmatic hernias)
• weight lifting
• heavy sports
• prolonged difficult labor
• pregnancy
• chronic constipation
• obesity

Symptoms and signs of diaphragmatic hernia of the esophagus and stomach

The main symptoms and signs of diaphragmatic hernia of the esophagus are as follows:

1. Constant heartburn. which increases after eating, in the supine position, when bending forward and down (for example, in order to tie shoelaces). Heartburn with diaphragmatic hernia is located at the bottom of the sternum.
2. Constant belching and bloating a - due to a hernia of the esophagus, a lot of air enters the stomach during meals
3. Belching food masses during sleep (a phenomenon that often occurs against the background of a hiatal hernia) can cause food masses to enter the respiratory tract and provoke a strong cough. accompanied by shortness of breath and fear of suffocation.

The ingress of food masses into the respiratory tract in patients with diaphragmatic hernias can cause frequently recurring bronchitis and pneumonia (often the right lung).

Due to the pressure of the esophagus and the upper part of the stomach, which have penetrated into the chest cavity through the esophageal opening of the diaphragm, there may be chest pain aggravated by coughing, persistent cough accompanied by shortness of breath (as in asthma).

Often, against the background of a diaphragmatic hernia, chest pains are observed resembling pain in angina pectoris (note that a diaphragmatic hernia can exacerbate the course of angina pectoris, therefore, if attacks of pressing or burning pain behind the sternum appear, lasting up to 5 minutes, you should consult a doctor as soon as possible).

Diagnosis of diaphragmatic hernia

Diagnosis and treatment of diaphragmatic hernia is carried out by gastroenterologists or surgeons. The following tests are used to confirm the diagnosis of diaphragmatic hernia:

• X-ray examination of the stomach with barium contrast - allows you to get an image of the part of the stomach and esophagus protruding into the chest

Fibrogastroscopy: allows you to clarify the condition of the mucous membrane of the esophagus and stomach

Diaphragmatic hernia treatment

Diaphragmatic hernia treatment consists of following a special diet, using medications to reduce the acidity of the stomach, and surgery.

Diet for the treatment of diaphragmatic hernia

Patients with diaphragmatic hernia are advised to limit the amount of food consumed at a time. Eat often, but little by little. Spicy, fatty, fried or salty foods should be excluded from the diet. You should also reduce your consumption of coffee and alcoholic beverages to a minimum.

Drugs for the treatment of diaphragmatic hernia

Medicinal treatment of diaphragmatic hernia is aimed at eliminating its main symptoms: belching and heartburn. For a detailed description of drug treatment for these symptoms, see Heartburn and GERD. In cases where chronic constipation is observed against the background of a diaphragmatic hernia, they must be treated (see Constipation)

Diaphragmatic hernia surgery

Diaphragmatic hernia surgery is recommended in the following cases:

During the operation, the abdominal part of the esophagus and stomach are pulled back into the abdominal cavity, and the esophageal opening of the diaphragm is narrowed and strengthened by a special method.