diaphragmatic hernia

Diaphragmatic break: description

In a diaphragmatic fracture, medically referred to as hiatal hernia, parts of the abdominal organs shift through an opening in the diaphragm (diaphragm) into the chest (thorax). The dome-shaped diaphragm consists of muscle and tendon tissue. It separates the breast from the abdominal cavity. It is also considered the most important respiratory muscle. It has three large openings: In front of the spine is the so-called aortic slit, through which the main artery (aorta) and a large lymphatic vessel pull. The main artery runs behind the abdomen and its organs. Through the second larger opening, the inferior vena cava runs – it is firmly fused with the surrounding tendon tissue of the diaphragm.

The esophagus passes through the third large hole, the oesophageus hiatus, where it flows into the stomach just below the diaphragm. The oesophageal opening forms a direct connection between the chest and the abdomen. Since the muscle tissue at this point is relatively loose, it can especially come here to a diaphragmatic fracture.

Hiatal hernias are subdivided according to the origin and location of the parts that pass into the chest cavity.

Extrahiate diaphragmatic fractures

The commonly used term diaphragmatic fracture usually means the organ displacement through the esophageal slit (Hiatus oesophageus), therefore called hiatal hernia. In addition, there are also diaphragmatic hernias in which organs of the abdominal cavity pass through other openings in the diaphragm. These are summarized by the term extra-pulmonary (ie lying outside the esophageal slit) diaphragmatic fractures. Thus, for example, there is a hole (Morgagni) at the junction with the sternum, through which bowel loops preferentially shift (Morgagni hernia, parasternal hernia). And a triangular gap in the back of the muscular diaphragm (Bochdalek gap) can also cause a vomit.

frequency

The diaphragmatic break through the esophageal slit is by far the most common form. Among them are found in about 90 percent of cases axial hernias. Ruptures on the side of the esophagus, the paraesophageal hernias, on the other hand, very rarely occur alone. They are usually found in mixed forms (type III hernias). In older people, diaphragmatic fractures are more common. If the hernia develops due to a misdeveloped diaphragm, it is the innate form. Doctors find a diaphragmatic defect in about two to five out of 10,000 births. Most are on the left side (80-90 percent).

In the German hospitals, according to federal health reporting in 2012, more than 10,000 diaphragmatic fractures were diagnosed. Women were affected about twice as often as men. Congenital diaphragmatic hernias were found in 237 newborns in the same year.

Diaphragmatic hernia: symptoms

Whether one has symptoms in a diaphragmatic fracture usually depends on the type and extent of the respective hernia.

Axial hiatal hernia

The type I diaphragmatic hernia usually has no symptoms. Patients often report heartburn and pain behind the sternum or upper abdomen. But it is less about diaphragmatic discomfort; Rather, the symptoms are due to concomitant reflux disease. Gastric contents, especially the acidic gastric juice, flow into the esophagus. Normally, a closing mechanism prevents this backflow: muscle pulls on the stomach entrance (lower esophageal sphincter) tighten and thus protect the esophagus from stomach acid. In addition, the esophagus opens very steeply into the stomach. This circumstance makes reflux more difficult.

The healthy diaphragm, however, supports this process, which is why the risk of reflux increases in the event of a fracture. Eventually the upper end of the diaphragm collapses and a so-called Schatzki ring is created. As a result, patients suffer from dysphagia or steakhouse syndrome: a piece of meat sticks and clogs the esophagus.

In some cases spasmodic epigastric pains in the upper abdomen appear as symptoms of diaphragmatic hernia. These arise when the break bag is pinched. If the diaphragm opening presses too much on the well-worn stomach section, damage to the stomach wall can occur. Doctors speak here of the Cameron ulcer.

Paraesophageal hiatal hernia

At the beginning of a type II diaphragmatic fracture usually no complaints occur. In the further course it is difficult for patients to swallow. In some sufferers, gastric contents flow back down the esophagus. Especially after eating, patients often feel an increased feeling of pressure in the heart and circulatory problems. Twists the hernia bag, his blood supply is disturbed and the contained portions of the stomach can die off. Doctors speak in this event of an incarceration, which is life-threatening.

As with the axial diaphragmatic fracture, the tissue of the stomach wall can be damaged. Under certain circumstances, the resulting defects bleed unnoticed. Approximately one third of all type II hernias are therefore first discovered by chronic anemia. The remaining two thirds find doctors by accident or they show up by swallowing. If a hiatal hernia causes severe symptoms, the hernia sac is usually very large. In extreme cases, the entire stomach moves into the chest.

Further diaphragmatic fractures

The symptoms of extra-diaphragmatic diaphragmatic fractures are similar. Some patients have no discomfort, while others have more complicated diaphragmatic hernias. As with the hiatal hernias, the contents of the hernia sac – intestinal loops or other abdominal organs – can die off and release toxins that are life-threatening for the body.

Take special care with newborns. A diaphragmatic fracture is almost always life-threatening. Because the overflowed parts of the abdominal cavity displace heart and lungs in the still small chest.

Diaphragm Fracture: causes and risk factors

A diaphragmatic fracture distinguishes between innate and acquired form. The latter has different causes and dimensions. Congenital diaphragmatic hernias, on the other hand, usually develop as a result of an incorrect development of the diaphragm.

Developmental disorders during the embryonic period

The diaphragm forms in two phases. First, a wall of simple connective tissue separates the thoracic and abdominal cavities. Since the diaphragm consists of two parts (septum transversum and pleuroperitoneal membrane), there is initially a gap. It closes faster on the right than on the left. In the second phase, the muscle fibers grow. If there is a disturbance during this time (fourth to twelfth week of pregnancy), a defect develops in the diaphragm. Through these gaps, abdominal parts can now move into the chest. Since at the beginning organ shells such as the peritoneum are not yet formed, the organs are free in the chest cavity.

About seventy to eighty percent of all paraesophageal hiatal hernias are due to a congenital diaphragmatic defect. Frequently there is a large opening in developmental dysplasia, through which the esophagus and the main artery are common (hiatus communis).

Risk factor body position

The axial diaphragmatic hernia is also called sliding hernia. The broken abdominal cavity contents can slip back and enter the chest again. So he slides back and forth between the chest and abdomen. The stomach sections shift mainly when lying or when the upper body is lower than the abdomen. If the affected person is upright, the displaced parts return to the abdominal cavity following gravity.

Risk factor pressing

The likelihood of a diaphragmatic fracture is increased when the abdominal muscles become tense. This “pressure” increases the pressure in the abdomen. As a result, the stomach just below the diaphragm is pushed upwards through the weak or defective diaphragm. The risk increases with forced exhalation, abdominal crunching and defecation.

Risk factor strong obesity and pregnancy

Similar to pressing, adiposity (obesity) and pregnancy also increase the risk of a diaphragmatic fracture. An excessive amount of fatty tissue in the abdomen (peritoneal fat) increases the pressure on the organs, especially when lying down. As a result, they are displaced – especially upwards. During pregnancy, the growing child in the uterus increasingly requires space in the abdominal cavity. The organs are pushed upwards. As a rule, such diaphragmatic hernia easily returns after birth.

Risk factor age

Already in a study of 1990, a relationship between the age and the occurrence of a diaphragmatic fracture was investigated. In people older than 70 years, it is possible to detect X-ray hernias in 70% of cases. Experts believe that the connective tissue of the diaphragm becomes weaker and the esophageal slit widens. In addition, the ligaments between stomach and diaphragm relax where the esophagus passes into the stomach. The esophagus opens thereby flatter in the stomach than normally. Doctors talk about cardiofundamental miscarriage or an open oesophageal-gastric junction, which increases the risk of diaphragmatic fracture.

Diaphragmatic fracture: diagnosis and examination

Many hiatal hernias are discovered by chance when the doctor performs an X-ray or control gastroscopy. Usually, the specialist in gastroenterology in the field of internal medicine, sometimes a pulmonologist (pulmonologist). Some patients suffer from heartburn in diaphragmatic fractures and should consult their GP with such symptoms.

Medical history (medical history) and physical examination

If a patient with diaphragmatic discomfort seeks a doctor, he will ask him specifically about the symptoms that occur: how the symptoms are explained exactly, since when and in what situations they occur and how they may be exacerbated. In this context, especially known, earlier diaphragmatic hernias of the patient are important.

Since even traumatic events such as surgery or an accident can damage the diaphragm, such information plays a crucial role. In about 30 percent of patients can be found in addition to the diaphragmatic fracture also a gallstone disease (cholelithiasis) and protuberances of the intestinal wall (diverticulosis). Medical is called these three frequently occurring diseases Saint-Triassic. The doctor is therefore also on the previous history of a disease. If bowel loops are displaced during the diaphragmatic fracture, the doctor with the stethoscope may be able to hear intestinal noises above the ribcage.

Further investigations

For the exact classification and planning of a diaphragmatic fracture treatment, the physician carries out further investigations.

Diaphragmatic break: treatment

A diaphragmatic fracture does not always have to be treated. Axial hiatal hernia is only operated on when symptoms such as chronic reflux disease occur. Due to the reflux of the gastric juice, the esophagus becomes inflamed and the mucous membrane is attacked. It can be followed by mucosal damage and bleeding. If reflux disease persists for an extended period of time, the risk of esophageal cancer is also markedly increased. If the mucous membrane has been damaged by a diaphragmatic fracture, surgery should also be considered.

In order to avoid possible complaints due to refluxing stomach acid, appropriate medications are also prescribed. They either reduce the amount of acid (proton pump inhibitor, histamine receptor blocker) or balance out the acidity (antacid).

Diaphragmatic hernia surgery

All remaining hiatal hernias are treated surgically. Even if symptoms of a diaphragmatic fracture can only occur late, the hernia sacs often increase more and more in the course of the disease. Complications such as disturbed food transport, a stomach twist or a trapped fracture content that can quickly die as a result, doctors operate as soon as possible. The diaphragmatic pleura that has passed through the thoracic cavity is then properly relocated back into the abdominal cavity. Then you narrow the gap and stabilizes this (Hiatoplastik). In addition, the gastric fundus, ie the dome-shaped upper curvature of the stomach, is sutured to the left underside of the diaphragm. At the end of the diaphragmatic phrenic operation, surgeons attach some of the stomach either to the anterior abdominal wall or to another part of the diaphragm (gastropexy).

If the diaphragmatic surgery only remedy the reflux disease, the so-called fundoplication according to Nissen. The surgeon wraps the stomach fundus around the esophagus and sutures the resulting cuff. This increases the pressure on the lower esophageal sphincter on the stomach and gastric juice can hardly flow upwards.

Plastic netting

If the diaphragmatic defect is too large, mostly plastic nets are used to close the fracture gap. Especially with congenital defects of the diaphragm caution is required. The neonates must be cared for intensive care, as the diaphragmatic fracture hardly allows adequate breathing. An artificial respiration is necessary then. Only when circulation and respiration are stable can surgery be performed.

Diaphragmatic hernia: disease course and prognosis

In about 80 to 90 percent of the sliding hernias no therapy is necessary. And even after surgery, about 90 percent of patients with diaphragmatic hernia are symptom-free. In neonates the prognosis depends mainly on how much the lung volume is limited. Since the diaphragmatic fracture already exists before birth, the lung on the affected side is usually underdeveloped. In severe cases, the mortality rate is approximately 40 to 50 percent.

complications

A diaphragmatic fracture is less favorable if complications occur. If, for example, the stomach or the contents of the hernia bag twist, their blood supply is shut off. As a result, the tissue inflames and dies. Toxins released as a result can spread throughout the body and cause severe damage (sepsis).

If the diaphragmatic fracture displaces large parts of the abdominal organs, the lungs and heart are restricted in the thorax. It comes to circulatory problems and respiratory distress. In these cases, rapid surgery is performed and the patient is cared for in an intensive care unit. In addition, bleeding from tissue damage causes chronic anemia.

change of lifestyle

Overweight and lack of exercise increase the risk of hiatal hernia. Diet and lifestyle should therefore be changed, that is, to do more sports and eat smaller meals. It is also advisable to stop eating right before bedtime. Especially in a known sliding hernia prevents a slightly elevated at night lying upper body, the renewed upward slipping of abdominal organs in the chest cavity. This also reduces heartburn and reduces the risk of reflux disease and its consequences.

Because most hernias are harmless and symptom-free sliding hernias, one goes diaphragmatic hernia usually without complications and his prognosis is good.