How the diaphragm hurts. Diaphragmatic hernia. Causes of defect formation and symptoms of the disease

Diaphragmatic hernia is a pathology that develops as a result of an increase in the width of the physiological opening in the diaphragm. Through the enlarged opening, organs located in the abdominal cavity can partially penetrate into the chest area. Usually we are talking about the cardia of the stomach, less often – about fragments of the small intestine. Treatment of hiatal hernia (HH) is carried out using conservative therapy or through surgery. The appropriate method is selected taking into account the type of hiatal hernia, the characteristics of the clinical case, the severity of the course, actual and predicted complications.

The share of this type of hernia in the total mass of such diseases is 2%. Typically, a diaphragm defect is discovered after obtaining the results of a fluoroscopic examination. The reason for prescribing a diagnostic examination is often patient complaints about various disorders in the gastrointestinal tract. If a diaphragmatic hernia is left untreated, the acidic contents of the stomach will leak into the walls of the esophagus. As a result, the mucous membrane of the organ is damaged, and pathologies such as esophagitis, stenosis, peptic ulcer, perforation of the esophagus, etc. develop.

There are axial (sliding) and paraesophageal hernia. The first type occurs in 90% of cases. Axial hiatal hernia, in contrast to the paraesophageal type, is characterized by penetration of the cardia (valve) of the stomach into the chest space.

Pathological changes often lead to cardia failure, which in turn causes esophagitis and other complications.

Sliding hernias often cause internal bleeding. Paraesophageal hernias are usually complicated by tissue entrapment. Depending on the causes of origin, congenital and acquired pathologies of the diaphragm are distinguished.

Causes of defect formation and symptoms of the disease

The diaphragm is a thin film that separates the chest and abdominal cavity. The film consists of muscle and connective tissue. Normally, it is statically attached to the ribs and spine. Physiological openings in the diaphragm area are intended for the spine, esophagus, and blood vessels. When the food opening of the diaphragm increases in size, the organs of the digestive system, including the stomach, can penetrate through it into the chest space. If the stomach area protrudes through the diaphragm opening, the patient experiences unpleasant symptoms. Among them:

• heartburn that occurs immediately after eating;
• pain localized in the hypochondrium or in the lower part of the sternum and aggravated by physical stress (bending forward, coughing, etc.). Pain is more common if the body is in a horizontal position. They can disappear spontaneously after assuming a vertical position, as well as after a reflex act of belching or vomiting;
• heart pain, which is identified with coronary disease. Painful sensations will spread to the area of ​​the shoulder blade and left forearm. The pain is easily relieved by taking nitroglycerin. When examining the ECG type, disturbances in the functioning of the heart are not detected;
• frequent belching, during which air or food debris comes out;
• signs of dyspepsia, such as heaviness in the stomach, discomfort that intensifies after eating, a feeling of fullness and early satiety (when eating even a small portion of food);
• intestinal disorders, which are usually observed with diverticulosis or ulcers in the duodenum.

In cases of complications of the disease, general symptoms appear more expressively. They are joined by other signs of functional disorders - acute girdle pain, increased body temperature, chills, general weakness, profuse sweating, pale skin. These symptoms are characteristic of inflammatory processes occurring in the pancreas and gall bladder.

Therefore, a thorough diagnostic examination is required before making a diagnosis. The main diagnostic method is radiography using a contrast agent (barium suspension). Additionally, to identify the severity of the disease, fibrogastroduodenoscopy is prescribed, which is the most informative method for examining the upper parts of the stomach.

A condition of strangulation of part of the intestines or stomach, which is accompanied by intense chest pain, vomiting, stool retention, and a sharp deterioration in health, is considered dangerous. A sliding (axial) hiatal hernia, occurring in a progressive form, leads to the development of peritonitis (inflammation of the peritoneum). Symptoms of a complicated diaphragmatic hernia include disturbances in the rhythmic contraction of the heart muscle (extrasystole, tachycardia) and indicate the need for emergency treatment. Main reasons:

• insufficient development of connective tissue that forms the opening of the diaphragm, intended for the esophagus;
• increased intra-abdominal pressure, especially in cases of chronic deviation from the norm;
• traction diverticula of the esophagus (single or multiple protrusions of the wall of the esophageal muscular tube). Pathology is formed due to fusion of the wall of the esophagus and surrounding organs. Typically, deformation occurs due to an inflammatory process.

Congenital pathology poses a serious threat to the life of an infant. A fetal hernia is diagnosed during the perinatal period, which makes it possible to immediately provide medical care to the newborn. The main reasons for the development of congenital pathological changes are regular physical overexertion during pregnancy, chronic diseases of the respiratory system identified in the expectant mother, poor nutrition, smoking, and alcohol abuse.

Pathology therapy

In cases where a hiatal hernia is diagnosed, treatment is carried out using conservative and surgical methods. When choosing a method for treating pathology, factors such as the degree of risk and the complexity of the course are taken into account. Surgery is indicated in cases where therapeutic treatment does not give the desired result. Conservative therapy is advisable to use when the hernial “sac” is small in size and the risk of strangulation is minimal. The drug treatment program for diaphragmatic hernia includes:

In some cases, the use of antipsychotics, antihistamines and sedatives is indicated. Patients are recommended to eat small meals. The daily diet is divided into 5-6 meals. The menu contains mostly fresh, carefully cooked dishes. Gastroenterologists advise completely eliminating smoked, spicy, too salty foods that provoke increased secretion of hydrochloric acid.

To completely cure the disease, you have to resort to surgery. If the hernia reaches alarming proportions and signs of infringement of internal organs are detected, the patient is scheduled for surgery. During surgery, the hernial sac is removed, and the enlarged opening of the diaphragm is sutured. If there is a deficiency of native tissue, the diaphragmatic opening is narrowed using “patches” made of artificial materials.

Treatment of illness at home

Conservative treatment of diaphragmatic hernia requires compliance with certain rules that will help avoid further progression of the disease. General recommendations for patients for effective therapy at home:

If you drink sodium bicarbonate mineral water, the discomfort from high acidity disappears, the balance of acids and alkalis is restored, and the symptoms of heartburn are reduced. Symptoms of the pathology intensify when the patient assumes a horizontal position. For this reason, it is recommended to eat no later than three hours before bedtime.

Nutritional features and recipes for folk remedies

Proper nutrition plays an important role in improving well-being and recovery. Principles of dietary nutrition for the diagnosis of hiatal hernia:

• replenishing the diet with easily digestible foods high in protein;
• thorough heat treatment and mechanical grinding of food. Preference is given to dishes with a light, soft, liquid consistency (soufflés, pureed soups, pureed porridges). It is allowed to prepare porridge from any cereal with the exception of rice. When preparing porridge, you need to take 1.5 times more water than indicated in the recipe. Then the mass will turn out boiled. Meat dishes are best prepared from minced minced meat (steamed cutlets and meatballs);
• drinking plenty of fluids. It is recommended to drink at least seven glasses of water daily.

Immediately after eating, you should not burden the body with physical activity. However, doctors also do not advise lying down. The horizontal position contributes to the formation of heartburn and the manifestation of other unpleasant symptoms of the disease.

Traditional medicine recipes:

The action of these drugs is aimed at eliminating unpleasant symptoms (heartburn, belching, bloating) and normalizing stool, which leads to a decrease in intra-abdominal pressure.

Diaphragm diseases cannot be underestimated. As scientists say, this organ is the second heart of the human body. If a person is healthy, every minute he performs about 18 motor acts, moving up and down 4 cm from the starting point. The diaphragm is the strongest human muscle, which compresses the vascular system of the abdomen and lymphatic vessels. Thanks to it, the veins are emptied, blood penetrates into the chest.

general information

It is sometimes difficult to notice diseases of the human diaphragm, but some pathologies immediately manifest themselves with severe symptoms. All diseases of the organ negatively affect its performance. Normally, a muscle contracts four times slower per minute than the heart. It provides a powerful blood pressure - much higher than that guaranteed by cardiac muscle tissue. This is due to the large area of ​​the organ and the ability to strongly push blood.

At regular intervals, the diaphragm compresses the liver, making bile flow easier and more accurate. At the same time, the muscle stimulates blood flow in the liver. The better the diaphragm works, the better the liver functionality, and this has a positive effect on the condition of a person suffering from various diseases. The opposite is also true: if the diaphragm does not work well, the functionality of all vital organs of the body deteriorates.

Problems: damage

For some diseases of the diaphragm, surgery is the most effective way to help those in need. This is often characteristic of cases of organ damage. Closed damage is possible due to an injury at work or received on the road. A person can fall from a great height and get concussed. The damage can be caused by strong pressure on the abdomen. Organ rupture is usually explained by a sharp increase in pressure in the abdominal cavity. In most cases, the damage is located at or near the tendon center and where the tendons meet the muscle fibers.

Up to 95% occur in cases of violation of the integrity of the left dome of the organ. The damage is accompanied by injuries to the pelvic bones, and the integrity of the chest may be compromised. Damage to the diaphragm often leads to disruption of the structure and integrity of organs located in the abdominal cavity. A wound or rupture of a muscular organ due to negative pressure in the sternum leads to a displacement of the stomach into the pleural area. The omentum shifts, sections of the intestines and liver move. The spleen may be damaged.

Open option

This disease of the diaphragm is possible when receiving a wound. More often this is a cut or stab wound. The cause may be a thoracoabdominal wound sustained from a firearm. It is known from statistics that such damage is almost always accompanied by other violations of the integrity and structure of internal organs. Organs localized in the sternum and abdomen are predominantly affected.

Clinic and clarification

If damage is suspected, x-ray diagnosis of diaphragm disease is the main method of assessing the patient's condition. At the acute stage of development, manifestations of trauma are observed. The patient is in shock. Weakness of the respiratory system, vascular, and cardiac is recorded. Bleeding is usually recorded, and bone fractures are possible. When the diaphragm is damaged, there is usually hemopneumothorax and peritonitis.

When diagnosing, it is necessary to evaluate compression and displacement of the mediastinal internal organs. Sometimes structures that protrude into the pleural zone are infringed. The doctor's task is to detect this fact in time. To do this, they resort to X-ray radiation.

What to do?

Treatment of diaphragm disease due to a wound or rupture involves surgery. Urgent surgical intervention is indicated. The defects need to be sewn up. The doctor places separate sutures, using material that cannot be absorbed. The abdominal organs are first returned to their place. The first stage of the operation is thoracotomy or laparotomy. The choice in favor of a particular option is determined by the characteristics of the patient’s injury.

Hernia

This term refers to a pathological condition in which organs normally located in the abdominal cavity are displaced into the sternum. By moving, defects that a person has from birth or acquired due to aggressive factors subsequently become. All cases of hernia are classified into acquired, congenital, and caused by trauma. False forms of the disease are known. This is the name for a condition in which there is no pathological sac in the peritoneum. Such pathologies can also be present from birth or acquired. The first ones appear if certain areas characteristic of the embryo remain ungrown in the diaphragm. At this stage of human development, the muscle structure has special pathways for communication between cavities (sternum, abdominal). Normally, as a person develops, they become overgrown. Cases of pathology are observed relatively rarely.

A more common disease of the diaphragm is a false hernia caused by trauma. It is most often explained by a wound to the internal organs, the muscles themselves. A previous isolated diaphragmatic rupture is possible, the dimensions of which do not exceed three centimeters. This can appear not only in the muscle block of the organ, but also in the tendon zone.

True hernia

A distinctive feature of this pathological condition is the presence of a hernial sac. It covers organs that have shifted relative to their normal anatomical position. This disease of the diaphragm is usually observed against the background of increased pressure inside the abdominal cavity, which leads to displacement of the organs located in it. If they pass through the sternocostal area, a parasternal hernia is diagnosed. More often, pathological conditions are identified that are named after researchers: Morgagni, Larrea. It is possible for internal structures to pass through poorly developed areas of the sternum diaphragm. In this case, a retrosternal hernia is diagnosed. If the internal organs move from their anatomically correct position through the lumbar-costal areas, a Bochdalek hernia is detected.

Both in the case of congenital pathology and in another variant of the disease, the hernial sac contains internal organs. These may include omentum, fiber. The latter is called parasternal lipoma. Atypically located true variants of diaphragmatic hernia are observed very rarely in medicine. They are somewhat similar to diaphragmatic relaxation. The key difference is the appearance of a hernial orifice, which is accompanied by a potential risk of strangulation.

Condition Clinic

Symptoms indicating diaphragm disease vary greatly from case to case. Much is determined by the level of displacement of internal elements into the pleural block. The scale of the manifestation of pathology is determined by the volume of displaced parts and the level of filling of hollow structures. Bend and compression play a role - this is usually observed near the gates of the pathological zone. The clinical picture is dictated by pulmonary collapse and mediastinal displacement. Much is determined by what the gate is, how large it is, and what configuration it has. It is known that false pathologies sometimes, in principle, are not characterized by pronounced symptoms. All manifestations are divided into general ones, associated with the respiratory, cardiac system and gastrointestinal tract.

Symptoms of diaphragm disease in humans include a feeling of heaviness in the pit of the stomach. The patient may notice pain in this area. The sensations spread to the chest, under the ribs. There is an increase in heart rate, increased heart rate, and shortness of breath. The symptoms are especially pronounced if you eat heavily. Often, gurgling and rumbling are felt in the sternum. Symptoms are noticeable in the half where the hernia is located. If the patient lies down, the symptoms become more active. Following a meal, vomiting of food that has barely entered the body is possible. If gastric volvulus is observed, the esophagus is bent, specific dysphagia is formed, large parts of nutrition move through the gastrointestinal tract much better than liquid.

Features of manifestations

Symptoms of diaphragm disease in humans include pain that occurs in attacks. This occurs if the hernia is strangulated. The sensations are localized in the area of ​​the sternum where the pinching occurred. Pain in the epigastric zone is possible if there is infringement in this place. There is a possibility of symptoms inherent in acute intestinal obstruction. If the hollow structure is infringed, the start of necrotic processes and wall perforation is possible. The consequence is pyopneumothorax.

A primary diagnosis can be assumed if the patient has previously been injured. An important role in formulating the diagnosis is played by the patient’s complaints and deterioration in the mobility of the sternum, smoothing out the spaces between the ribs on one half of the body. Doctors involved in the diagnosis, clinic, and treatment of diaphragm disease note that in many patients with such a hernia, the abdomen sinks. This is more characteristic of the case of long-term existence of pathology, large dimensions of the process. Over the half of the sternum, corresponding to the hernia, dullness and tympanitis are observed, the intensity is determined by the fullness of the gastrointestinal tract. The doctor's task is to listen to intestinal peristalsis. Possible splashing, noise, weakness of respiratory noise, its disappearance. Mediastinal dullness may spread to unaffected areas.

Instrumental examination

Before formulating a conclusion, it is necessary to make an X-ray diagnosis of diaphragm disease. Additionally, a CT scan is sometimes required. If the gastric cavity has shifted into the sternum, there is a high horizontal fluid level on the left side. With small intestinal prolapse, studying the lung field shows areas of shadow and light. Displacement of the liver and spleen on x-ray is reflected by a darkened area of ​​the lung field. In some patients, the diaphragmatic dome and the abdominal organs protruding above it are clearly visible.

Sometimes a contrast X-ray examination of the gastrointestinal tract is recommended. This may indicate that parenchymal internal organs have fallen out or are hollow. During the study, the exact position of the hernia gate and its dimensions are determined. They start from information about compression of displaced areas. Sometimes pneumoperitoneum is necessary to make an accurate diagnosis. If the hernia is false, air moves into the pleural zone. On x-ray, the result will be consistent with pneumothorax.

Therapy

With the above symptoms, treatment of diaphragm disease is practiced surgically (the risk of strangulation is high). If the pathology is localized in the right half of the body, the operation is transthoracic. The parasternal scenario requires an upper laparotomy. If the pathology is localized on the left, transthoracic access is required. First, the adhesions are separated, then the edges of the defective area are released, the zones that rise from there are brought down to the peritoneum, and then the damaged block of the diaphragm is sutured. Interrupted sutures are required. These should be separate. The surgeon's task is to make a duplication. Sometimes the defect is very large. This requires the use of synthetic products to block it. They use those made of lavsan or Teflon.

If a retrosternal hernia is established, Larrea, the organs that have shifted from the placed blocks are transferred lower, then the bag is turned out and cut off. The next stage is the formation of seams in the form of the letter “P”, followed by tying. This is how the defective edges are processed, then the posterior vaginal sheet of the peritoneal muscles. The next stage of the surgeon’s work is processing the ribs and sternal periosteum.

Nuances and cases

If, with the above symptoms of the disease, treatment of the diaphragm is necessary against the background of pathology localized in the lumbar-costal area, separate sutures are made to suture the diaphragmatic defect. The doctor's task is to form a duplicate.

If the hernia is strangulated, a transthoracic approach is required. The pinching ring is cut. The next step in the doctor’s work will be to study the filling. If the prolapsed organs are still viable, they need to be reset into the peritoneal area. If the changes are irreversible, it is necessary to remove the affected areas. The final step is suturing the muscle organ defect.

Hiatal hernia

This diaphragm disease can be acquired during life or inherited from birth. All cases are divided into paraesophageal and axial. The latter are also called sliding ones. In fact, such a pathology is a protrusion of the gastric cavity through the opening of the esophagus, anatomically provided in the diaphragm. The main percentage of cases of this disease do not have severe symptoms. If acid reflux worsens over time, symptoms consistent with gastroesophageal reflux disease (GERD) may occur. To make a diagnosis, an x-ray is indicated. The patient must first take one sip of barium sulfate. The therapeutic course is chosen based on the symptoms of the case. Treatment is necessary if typical manifestations of GERD are observed.

The etiology of the pathology is still unclear. It is believed that the hernia appears as a consequence of spraining the ligaments of the fascia of the diaphragmatic fissure and the esophagus. Most often, a sliding form of the disease is observed. The gastroesophageal junction in patients with this disease is located above the diaphragmatic level, and a certain percentage of the stomach is also located above. If studies show the junction is anatomically correct, some percentage of the stomach is adjacent to the esophagus within the opening.

Case Features

A hernia is an abnormal protrusion. Such a disease of the diaphragm according to a sliding scenario is recorded in approximately 40% of people who came for a preventive examination. The phenomenon is relatively widespread. More often it is discovered completely by accident, when the patient is sent for an X-ray examination due to some other reason. With this disease of the diaphragm, clinical recommendations are difficult to formulate due to the problems of determining the relationship between symptoms and the presence of the disease. Statistical studies show that the main percentage of GERD sufferers have such a hernia. But among those with such a hernia, GERD was detected in less than half.

A sliding hernia is a disease of the diaphragm, the symptoms of which for most people do not appear at all. Less commonly, patients report pain in the sternum. There may be other sensations that indicate reflux. If the pathology is formed paraesophagally, it does not manifest itself with any sensations. If we compare the course of the case with the sliding form, we should note the likelihood of strangulation of the esophageal opening. Therefore, there is a risk of complications in the form of strangulation. Any type of hernia can provoke massive bleeding in the gastrointestinal tract and cause a hidden source of bleeding.

Clarification and treatment

If, based on symptoms of diaphragm disease or no symptoms at all, the doctor believes that it is necessary to check the patient for the presence of a hiatal hernia, an X-ray examination is prescribed. Barium sulfate is used for ascertaining. If the pathology is very large, there is a higher probability of identifying it completely by chance, when the patient is sent for an X-ray examination of the sternum. If the pathological process is small, the only reliable modern detection method is fluoroscopy with preliminary administration of barium sulfate.

If a sliding hernia is detected, there are no symptoms of the disease, and specialized treatment is usually not prescribed. If symptoms characteristic of GERD are observed, therapy is chosen based on this diagnosis. For diaphragm disease, hospital surgery is indicated only in the case of the paraesophageal type due to the likelihood of strangulation. In the case of a sliding type of hernia, sometimes surgery is required if an internal bleeding site has formed. There is a possibility of complications in the form of peptic esophageal stricture, which also requires surgical measures. If GERD does not respond to conservative therapy for a long time, surgery may be recommended.

Paraesophageal hernias: features

Such diseases of the diaphragm are divided into two categories: antral, fundal. Through the opening of the diaphragm near the esophagus, gastric and intestinal tissues can move to the mediastinum. The fundic type of flow is more often identified. The clinical picture is determined by the characteristics of the contents of the hernia sac, as well as the level of movement of organs from the outside. The functionality of the esophageal sphincter closure is not impaired. Possible manifestations of gastrointestinal dysfunction. Sometimes the disease is detected when neuromuscular diseases diagnosed through ultrasound of the diaphragm are suspected. A hernia can manifest itself as improper functioning of the respiratory system or disruption of the functionality of the cardiovascular system. More often, displacement of the stomach into the sternum cavity is detected.

Carrying out sternal fluoroscopy allows you to detect a heart shadow with a rounded light block. Sometimes the liquid level is reflected. If the stomach contains a contrast agent, it is possible to determine where and how the prolapsed block is located, and how it is located relative to the cardia and esophagus. If the symptoms suggest a polyp, there is a suspicion of a peptic ulcer or gastric oncology, esophagogastroscopy is necessary.

Relaxation of the diaphragm

This term refers to a pathological condition in which the diaphragm becomes thinner and moves upward along with nearby organs, while the attachment line often remains the same. Congenital cases of this disease are possible due to underdevelopment or absolute muscle aplasia. Possibly an acquired disease, in most cases caused by damage to the nervous system that feeds the diaphragm. There is a possibility of an absolute process in which the dome is completely affected and moved. This is most often seen on the left. An alternative option is a limited pathological process in which one of the sections of the diaphragm becomes thinner. This is most often observed on the right in the anteromedial zone.

In the case of relaxation, the lung on the side of the affected area is compressed, the mediastinum shifts in the opposite direction, gastric volvulus or a similar pathology of the intestinal tract in the bend area near the spleen is possible.

Relaxation on the right in a limited area does not manifest symptoms. If the process occurs on the left, the symptoms are similar to a hernia, but there is no risk of strangulation, since there is no hernial orifice. To make a diagnosis, the displacement of internal organs is studied, the condition of the lungs and mediastinal structures is assessed. Instrumental diagnostic methods - CT, x-ray examination.

Diaphragmatic hernia is a displacement of the abdominal organs into the chest cavity, which occurs through the esophageal opening of the diaphragm (therefore, the disease has another name - hiatal hernia). This is a chronic disease with periodic relapses, significantly worsening a person’s quality of life.

Diaphragmatic hernia is a more common condition than it might seem. It occurs in 0.5% of the population, but in half of the patients the clinic does not manifest itself, they do not go to doctors, and the diaphragmatic hernia remains undetected.

Causes

A diaphragmatic hernia is formed due to the stretching of the connective tissue membrane located between the esophagus and the opening of the diaphragm, through which the esophagus passes from the chest cavity to the abdominal cavity.

The reasons why the esophageal opening of the diaphragm increases in size are not fully understood. Factors contributing to membrane weakness and hiatus laxity:

In turn, displacement of the esophagus is observed when:

• digestive tract (disorders of natural muscle contractions);
• pathological conditions of the esophagus itself - scars, tumors, narrowing of the lumen.

The genetic factor is confirmed by the fact that hiatal hernia often occurs in people with other congenital connective tissue disorders - with:

• flat feet;
• Marfan syndrome (such patients are tall, with long limbs and elongated fingers).

The most common factor contributing to membrane weakness is age-related changes in it. Young people may suffer from frequent diseases of the respiratory and digestive organs, accompanied by reflux, but do not suffer from diaphragmatic hernias. On the other hand, the incidence of hiatal hernia increases sharply after 60 years of age - even if such patients were not sick at a younger age or adhered to a proper diet and did not suffer from reflux, vomiting or hiccups.

The immediate cause that most often provokes the occurrence of a diaphragmatic hernia is an increase in intra-abdominal pressure. It is observed in such conditions and processes as:

• strong ;
• frequent and prolonged respiratory diseases, accompanied by frequent coughing attacks;
• chronic diseases of the gastrointestinal tract, accompanied by frequent vomiting;
• loose fluid in the abdomen (ascites);
• huge tumors in the abdominal cavity;
• pregnancy.

The most common cause of increased intra-abdominal pressure is coughing.

Development of the disease

Before passing into the stomach, the esophagus passes into the abdominal cavity through the esophageal opening of the diaphragm, to which it is connected circumferentially by a connective tissue membrane. Thanks to it, a tightness is ensured between the abdominal and thoracic cavities. This membrane is quite elastic - when pressure builds up in the abdominal cavity, it can stretch.

Due to frequent contractions (or congenital insufficiency), the connective tissue elements of the diaphragmatic-esophageal membrane soon wear out and cease to act as a shock absorber - the tightness between the thoracic and abdominal cavities is broken. With subsequent increases in abdominal pressure, the abdominal organs put pressure on the weakened membrane - after a while it is no longer able to hold the abdominal organs, which, with an increase in intra-abdominal pressure, rush into the chest cavity. This is how a hiatal hernia occurs.

The most common types of hernia that develop are:

• sliding– when the area where the esophagus passes into the stomach and a fragment of the stomach itself enters the chest cavity;
• paraesophageal– the esophagogastric junction remains in the abdominal cavity, but part of the stomach penetrates through the esophageal opening and is located above the diaphragm.

A sliding hernia in most cases is determined by chance - it is found in 40% of patients who are performed for some other reason.

Therefore, if a patient has problems with the gallbladder, stomach or intestines, it would be useful for him to be examined for the presence of a hiatal hernia.

Symptoms of diaphragmatic hernia

The most common and characteristic symptoms by which a patient may be suspected of having a hiatal hernia are the following:

• pain;
• signs of backflow of stomach contents into the esophagus.

Pain occurs:

Characteristics of pain with diaphragmatic hernia:

• feels dull;
• the intensity is moderate, patients are able to tolerate it; severe pain is extremely rare;
• most often localized behind the upper third of the sternum;
• may spread along the esophagus;
• in some cases it radiates to the back and between the shoulder blades;
• worsens when trying to bend over.
• In most cases, pain appears:
• after eating (especially large meals);
• during or after physical activity;
• during cough;
• with bloating;
• in a lying position.

It is characteristic that such pain disappears after:

• belching;
• vomiting (sometimes patients artificially induce it for relief);
• deep breath;
• transition to a vertical position;
• taking water or alkaline solutions.

Signs reflux:

Belching – the most common sign of reflux. Its characteristics for diaphragmatic hernia are as follows:

• observed almost immediately after eating;
• can be very pronounced, sonorous;
• during belching, a sour taste is felt in the mouth (due to sour gastric contents), often with a bitter taste (due to an admixture of bile).

Regurgitation with diaphragmatic hernia has the following characteristics:

• most often observed after eating (especially in a lying position);
• in half of the cases it can bother you at night (the so-called “wet night pillow” symptom);
• regurgitation of food is observed, and if repeatedly, after a short time - with sour stomach contents;
• Most often, a small volume of stomach contents is regurgitated - from 10 to 20 ml, but with exacerbation of signs of a diaphragmatic hernia, the volume of regurgitated food can be 2-3 times greater.

Dysphagia develops as a result of obstruction of the esophagus, but this is not a permanent sign of a diaphragmatic hernia. Characteristics of dysphagia:

• the patient complains of an unpleasant pressing feeling behind the sternum during the act of swallowing - often characterizes it as “like a stake”;
• this difficulty in passing food through the esophagus is caused by taking too hot or too cold a liquid, eating in a hurry or in a stressful situation;
• There is a physiological paradox: with dysphagia, solid food passes through the esophagus, although with difficulty, but much easier and faster than liquid or semi-liquid food.

Pain behind the sternum appears only in the presence of reflux.

Heartburn – this is one of the most indicative signs of a diaphragmatic hernia. In some patients, it is the leading sign of diaphragmatic hernia. Characteristics of heartburn with hiatal hernia:

• noted immediately after eating;
• more pronounced if the patient is in a supine position;
• very often occurs at night, even if several hours have passed after eating;
• often subjectively unbearable; patients say that it is easier for them to endure the pain of a hernia than heartburn.

Hiccups observed in a small number of patients with diaphragmatic hernia (according to various sources - from 3 to 7%). But in the absence or scarcity of other symptoms, it may suggest the presence of a hernia. Hiccups are explained by the fact that the hernial protrusion irritates the phrenic nerve, which causes chaotic, uncontrollable contractions of the diaphragm. Characteristics of hiccups in diaphragmatic hernia:

• provoked by food intake;
• manifests itself in the form of protracted attacks lasting several hours, and in severe cases – several days.

Burning and pain in the tongue appear with severe reflux– reflux of acidic stomach contents into the oral cavity, which causes a burn to the mucous membrane of the tongue. Such contents can also enter the larynx, causing hoarseness.

In most cases, diaphragmatic hernias are asymptomatic. First of all, this applies to variants when only a fragment of the stomach penetrates into the chest cavity (paraesophageal hernia). Sliding hernias are clinically more indicative and in some cases are manifested by pain and signs of reflux.

At the same time, complications are more typical for paraesophageal hernias.

Complications of diaphragmatic hernias

In addition to the fact that a diaphragmatic hernia can be detected by chance, it is often diagnosed due to complications. . There are many types of complications of hiatal hernia. The main ones are:

Strangulation is the most difficult and dangerous complication of a hiatal hernia. It occurs when an abdominal organ, having entered through the esophageal opening of the diaphragm, cannot slide back and is compressed in the hernial sac, as well as along the circumference of the sac due to contraction of the connective tissue elements of the membrane between the opening and the esophagus. Signs of infringement:

• increased pain syndrome;
• and multiple with blood;
• disorders of the cardiovascular system - severe, accelerated heartbeat, sharply reduced blood pressure, blue discoloration of the patient’s skin;
• the lower part of the chest seems to bulge, breathing lags behind;
• on the chest organs are shifted to the healthy side.

The most indicative sign of strangulated diaphragmatic hernia is pain. Their characteristics are as follows:

• pain increases sharply and becomes intense;
• the pain is mainly in the area, but can also be felt in the area and radiates to the area between the shoulder blades;
• the nature of the pain is at first similar to contractions, then becomes constant;
• pain is not relieved by eating, drinking water or staying in any position; in rare cases, the pain subsides slightly when the patient is positioned on the left side.

Solarite – This is a lesion of the solar plexus. The plexus itself is a tangle of autonomic nerve fibers, which in many cases are affected secondarily, due to some other diseases - in this case, due to a diaphragmatic hernia. Signs that a diaphragmatic hernia has become complicated by solaritis:

• pain becomes more severe, burning;
• pain intensifies if you press on the solar plexus area;
• Pain relief occurs if the patient takes a knee-elbow position or leans forward.

Bleeding sooner or later complicates the diaphragmatic hernia. About 20% of patients suffer from acute severe bleeding, about 25% suffer from hidden bleeding. The most common cause of bleeding from a hiatal hernia is ulcers and erosions of the esophagus and stomach. The mechanism of such bleeding is as follows:

• the stomach or intestinal loop very often migrates from the abdominal cavity to the chest cavity and back;
• this provokes trauma to the vessels passing in the mucosa and under it;
• after some time, trauma results in a violation of the integrity of the walls of blood vessels, and bleeding begins.

Often, bleeding that complicates a diaphragmatic hernia is caused by vomiting.

Signs of gastrointestinal bleeding with diaphragmatic hernia:

• streaks of blood appear in the vomit;
• stool – dark, semi-liquid;
• deterioration of the patient’s general condition – weakness, apathy, lethargy;
• deterioration of red blood counts.

With hiatal hernias, anemia most often develops not because of acute massive bleeding, but because of constant hidden bleeding. This .

Anemia occurs less frequently due to the fact that, due to constant displacements into the chest cavity, the upper part of the stomach, in which vitamin B12 is produced, atrophies.

You need to pay close attention to sudden anemia in a person who has not previously been ill, since it may be the only sign of a hiatal hernia (remember that such hernias are often asymptomatic). In fact, it is not sudden; its development is preceded by repeated hidden bleeding. Hidden means that there is no visible discharge of blood from the gastrointestinal tract; blood can only change the stool (it becomes semi-liquid and dark, like tar, which is why it is officially referred to as “tar-like feces”).

Manifestations of anemia, which complicates a diaphragmatic hernia, are quite typical for anemia in general - these are:

• general weakness;
• frequent;
• darkening and " ;
• pallor of the skin and visible mucous membranes.

But the fact that this anemia is iron deficiency and indicates a diaphragmatic hernia in the absence of its other symptoms is evidenced by the so-called sideropenia syndrome, which includes:

• dry skin;
• brittleness and spotting of nails due to malnutrition;
• perversion of taste and smell.

Anemia is confirmed by a deterioration in the blood test - low levels:

• red blood cells;
• hemoglobin.

Diagnostics

Since hiatal hernia in most cases is asymptomatic (at least uncomplicated), additional examination methods are important in the early diagnosis of this disease - primarily instrumental:

• with contrast;
• fiberoscopy;
• esophagomanometry.

X-ray using a contrast agent is the most revealing method in diagnosing diaphragmatic hernia.

The patient is given a suspension of barium sulfate to drink, which fills the stomach and esophagus and allows their contours to be determined on an x-ray. In particular, the part of the stomach that has prolapsed into the chest cavity, the shape, size and bends of the esophagus, as well as the location of the esophageal opening of the diaphragm, which appears on an x-ray image as “notches” on the contours of the stomach, will be visible.

X-ray with contrast also allows you to identify and clarify details when a diaphragmatic hernia is pinched - it is determined by a characteristic “bubble” with air.

– examination using a probe, equipped with special optics, which helps to see the gastrointestinal tract from the inside and identify its changes resulting from a diaphragmatic hernia:

• inflammation, erosion, bleeding, ulcers of the esophagus and stomach;
• shortening of the esophagus, which is determined by detecting a decrease in the distance from the patient’s fangs to the stomach (measured using the probe itself).

Due to the formation of a diaphragmatic hernia, an area of ​​increased pressure is determined above the diaphragm, which is measured during esophagomanometry. Decoding the measurement data will help determine the condition of the esophageal opening of the diaphragm.

Laboratory examination methods are not of particular importance in the diagnosis of hiatal hernia. . will help identify anemia and, in the absence of any symptoms, suspect hidden bleeding, which may indicate the presence of a diaphragmatic hernia.

Treatment of diaphragmatic hernia

If a small fragment of the stomach enters the chest cavity without clinical consequences for the patient, no specific treatment is carried out. It is enough to adjust the diet and physical activity so that the patient can avoid uncomfortable sensations, if any, and if they do not exist, prevent the occurrence of such sensations.

If, during repeated instrumental examination, progression of the disease is observed (an increase in the diameter of the esophageal opening of the diaphragm, an increase in the time the abdominal structures remain in the abdominal cavity, the occurrence of complaints), such a hernia should be operated on to avoid the risk of strangulation. The purpose of the operation is to narrow the enlarged esophageal opening of the diaphragm and strengthen it.

In case of a strangulated diaphragmatic hernia, if the symptoms do not decrease or even increase, surgical intervention is performed as an emergency.

Prevention

To prevent the occurrence of a diaphragmatic hernia, the causes of its occurrence and provoking factors should be eliminated - primarily diseases of the respiratory system with frequent coughing, gastrointestinal diseases with vomiting, flatulence, and free fluid in the abdominal cavity. Often, a diaphragmatic hernia regresses after childbirth.

Forecast

With the right medical approach, the prognosis is favorable. Strangulations of a diaphragmatic hernia with all the ensuing consequences (in particular, necrosis of the strangulated contents) occur much less frequently than strangulations with other types of hernias.

Kovtonyuk Oksana Vladimirovna, medical observer, surgeon, consultant doctor

Lecture topic: Diseases of the diaphragm.

The purpose of the lecture: training, education.

Relevance: Among various pathological processes affecting the organs of the thoracic and abdominal cavities, diseases of the diaphragm occupy a special place, primarily due to anatomical and physiological characteristics, as well as the extraordinary complexity of their clinical diagnosis.

The anatomical position of the diaphragm is the undoubted reason for its complete inaccessibility to study by general surgical clinical methods (palpation, percussion, auscultation).

In this regard, pathological processes of the diaphragm remained inaccessible for clinical diagnosis for a long time, and diseases of the diaphragm were considered rare. However, it is known that there are no rare diseases, but only rare diagnoses, which indicates that practicing doctors are insufficiently familiar with a particular disease and is the cause of serious diagnostic and treatment errors.

Materials:

General view of the diaphragm from below
1-tendon center; 2-lumbar part of the diaphragm; 3-rib part; 4-breasted part; 5-sternocostal triangle; 6-lumbocostal triangle; 7-aorta; 8-esophagus; 9-inferior vena cava.

DIAPHRAGM DEVELOPMENTAL DISORDERS

1. 
   Partial defects:
   1) posterolateral
   2) anterolateral
   3) central
   4) esophageal-aortic
   5) phrenopericardial
2. 
   Bilateral aplasia
3. 
   Unilateral aplasia
   Scheme of localization of partial congenital defects of the diaphragm.
   1-posterolateral defect; 2-anterolateral defect; 3-central; 4-esophageal-aortic; 5-phrenopericardial; 6-sided aplasia of the diaphragm.

Classification of hiatal hernias

I. Sliding hiatal hernia

Without shortening of the esophagus

1. 
   Cardiac
2. 
   Cardiofundal
3. 
   Subtotal gastric
4. 
   Total gastric

1. 
   Cardiac
2. 
   Cardiofundal
3. 
   Subtotal gastric
4. 
   Total gastric

1. 
   Fundal
2. 
   Antral
3. 
   Intestinal
4. 
   Gastrointestinal
5. 
   Omental

Causes of hiatal hernia:

Predisposing factors:

1. 
   Expansion of the esophageal opening of the diaphragm due to atrophy of the muscle fibers of the medial crus of the diaphragm;
2. 
   Stretching of the esophageal-phrenic membrane;
3. 
   Shortening of the esophagus (spastic or cicatricial);
4. 
   Constitutional characteristics of the body, weakness of connective tissue.
5. 
   Surgical interventions on the cardia, diaphragm; Gastric resection changes the His angle.

1. 
   Obesity, ascites, pregnancy, large abdominal tumors;
2. 
   Cough, constipation, flatulence, frequent repeated vomiting.

1. 
   PAIN
2. 
   HEARTBURN
3. 
   DYSPHAGIA
4. 
   RETURNING
5. 
   REFLECTIVE ANGINA
6. 
   VOMIT
7. 
   SCAR STENOSIS
8. 
   REPEATED STOMACH BLEEDINGS
9. 
   CHRONIC HYPOCHROMIC ANEMIA

1. 
   X-ray methods.
2. 
   Esophageal pH-metry.
3. 
   Esophagoscopy (“gaping cardia”, hyperemia, edema, hemorrhages, fibrin, ulcers, erosions).
4. 
   Esophagomanometry - the area of ​​increased pressure will be above the hernial orifice.

1. 
   bleeding;
2. 
   perforation of esophageal ulcers;
3. 
   aspiration pneumonia;
4. 
   cicatricial stenosis of the lower third of the esophagus;
5. 
   partial or complete infringement.

1. 
   Elimination of factors that increase intra-abdominal pressure:
   • 
     Obesity
   • 
     Binge eating
   • 
     Constipation
   • 
     Working in an inclined position
   • 
     Pregnancy, ascites

4. Anti-ulcer diet.

Surgical treatment of hiatal hernia

Operation stages:

1. 
   Reduction of the stomach from the mediastinum into the abdominal cavity;
2. 
   Mobilization of the esophagus, cardia and fundus of the stomach;
3. 
   Narrowing of the hernial orifice – crurorrhaphy;
4. 
   Fundoplication - wrapping the esophagus with the fundus of the stomach according to Nissen (thus creating a valve that prevents reflux);
5. 
   Esophagophundoraphy - suturing the fundus of the stomach to the esophagus

Cutting off an inside-out hernial sac

Applying U-shaped sutures to the hernial orifice

Transabdominal fundoplication with mediastinalization of the cardia:

Fixation of the stomach to the edges of the dilated hernial orifice

Transpleural fundoplication for sliding hernia with shortening of the esophagus

Performing a Nissen fundoplication

The auxiliary hole in the diaphragm is sutured, the stomach is sutured to the edges of the hernial orifice

DIAPHRAGM RELAXATION

DIAPHRAGM RELAXATION – relaxation or drop in tone of the diaphragm due to underdevelopment or absence of the diaphragmatic muscle.

CLINICAL FORMS

1. 
   Asymptomatic;
2. 
   With erased clinical signs;
3. 
   With pronounced clinical signs;
4. 
   Complicated (acute gastric volvulus, gastric bleeding, gastric ulcer).

1. 
   respiratory;
2. 
   cardiovascular;
3. 
   gastrointestinal.

Physical examinations reveal:

1. 
   Increasing Traube space.
2. 
   Shift upward of the lower border of the left lung.
3. 
   Absence or weakening of breathing sounds in this area.
4. 
   Detection of bowel sounds, rumbling and splashing sounds over the chest.
5. 
   Displacement of cardiac dullness.
6. 
   Decrease in vital capacity and Stange test. The X-ray method of examination is of decisive importance.

Emergency surgery is indicated:

In case of RD complicated by diaphragm rupture,

In case of RD complicated by acute gastric volvulus,

For RD complicated by gastric bleeding,

In case of RD complicated by asphyxia in newborns.

Plastic surgery for relaxation of the diaphragm

Sewing the base of the fold of the relaxed diaphragm with U-shaped seams

The fold of the relaxed diaphragm is sutured to the preserved muscles of the diaphragm

Dissection of the relaxed portion of the diaphragm dome

Sewing the edges of the dissected dome of the diaphragm

Means: multimedia equipment, codegrams, demonstration of patients.

1. 
   Surgical diseases of the abdominal organs. Gastroenterological module: educational method. manual for 5th year medical students, pediatrician. and medical prevention. fak. / ed. S. V. Ivanova; State Educational Institution of Higher Professional Education KSMU Federal. health and social agencies Development, Department surgeon. diseases No. 1. – Kursk: KSMU, 2006. – 103 p.: ill.
2. 
   Vasilenko V.Kh., Grebnev A.L. Hiatal hernia. – M., Medicine. – 1978
3. 
   Petrovsky B.V., Kanshin N.N., Nikolaev N.O. Diaphragm surgery. – M., Medicine, - 1982

This tone is maintained both at low (enteroptosis) and at high standing of the diaphragm (ascites, flatulence, pregnancy), ensuring the effectiveness of active contraction of the diaphragm during inhalation. The diaphragm is the main respiratory muscle, also involved in blood circulation. Rhythmic respiratory movements of the diaphragm contribute to breathing from the moment of birth and do not stop completely, as determined by x-rays, even during a pause during Chanestokes breathing. The diaphragm is especially important for ventilation of the lower parts of the lungs, where atelectasis most often develops, for example, after surgery. The diaphragm, contracting, brings together the edges of the lower opening of the chest, being to a certain extent an antagonist of the intercostal muscles, which raise the lowered arches of the ribs and thereby expand the lower opening of the chest. Interaction with the intercostal muscles ensures a particularly effective increase in lung volume. When the diaphragm is paralyzed, during inhalation the false ribs diverge to the sides, and the epigastric region bulges.

The participation of the diaphragm in blood circulation is also significant. Closely entwining the liver with its legs and dome, the diaphragm, during inhalation, squeezes venous blood out of the liver and at the same time relieves intrathoracic pressure, thus facilitating the suction of venous blood from the main venous collectors to the heart.

The diaphragm performs its complex function as a muscular respiratory and circulatory organ thanks to complex innervation, which also determines numerous neuroreflex reactions of the diaphragm when central nervous and autonomic regulation is disturbed.

With pulmonary emphysema, a long-term increase in the function of the diaphragm leads initially to its hypertrophy, and then to degenerative changes (fatty degeneration) with decompensation of function, which is of great importance in the development of respiratory and pulmonary-cardiac failure in lung diseases. Atrophy of the muscular layers of the diaphragm is found in cases of paralysis of the phrenic nerve, for example, after therapeutic phrenic exeresis for pulmonary tuberculosis.

The standing height and movements of the diaphragm in the clinic are judged by the visible movement of the diaphragmatic shadow during breathing (Litten's phenomenon), by the percussion border of the lungs with the abdominal organs, as well as by the respiratory movements of the false ribs, partly by the rhythmic change in retraction and bulging of the epigastric region. A low position of the diaphragm is observed with emphysema, effusion pleurisy, pericarditis, etc., a high position with ascites, flatulence, intra-abdominal tumors. The most clear data is revealed by fluoroscopy.

Painful diaphragmatic syndrome is associated with the fact that the central part of the diaphragm is innervated by p. phrenicus, why pain is transmitted through the fourth cervical nerve to the neck and to the area of ​​the trapezius muscle (brachialis, acromial sign) and there are pain points along the intercostal spaces near the sternum (especially on the right) and between legs of the sternocleidomastial muscle. The peripheral part of the diaphragm is innervated by the intercostal nerves, and the pain is referred to the lower part of the chest, the epigastric region and the abdominal wall; reflex pains such as angina pectoris are also observed, transmitted through n. vagus

Diaphragmatitis

Diaphragmatitis is usually called inflammation of the pleura covering the diaphragm (i.e., diaphragmatic pleurisy itself), sometimes combined with damage to the diaphragmatic muscle itself. With effusion pleurisy, especially purulent one, the inflammatory process often spreads to the diaphragm. In this case, disfiguring diaphragmatitis may occur with a significant loss of its function as one of the severe consequences of pleurisy; a similar phenomenon occurs with pericarditis, especially purulent ones, with mediastinopericarditis, as well as with peritonitis, for example, encysted subdiaphragmatic abscess, in which pus finds its way out through the lymphatic slits into the bronchus. Abdominal syndrome with lobar pneumonia, pleurisy, rheumatic pericarditis may be caused by the transition of the inflammatory process through the lymphatic pathways of the diaphragm to the adjacent parts of the peritoneum.

Clonic spasm of the diaphragm (hiccups) is usually a harmless phenomenon, sometimes life-threatening, more often it occurs reflexively in response to irritation of neighboring organs, when the stomach is overloaded, when peritonitis begins, when the phrenic nerve is irritated by a tumor of the mediastinum, an aortic aneurysm, or from excitation of a center located nearby with respiratory, agonal hiccups, which have such a poor prognostic value, uremic hiccups, hiccups with cerebral apoplexy, encephalitis, with venous stagnation of the brain.

Treatment. Skin irritation (mustard plasters, rubbing the skin with brushes, ether under the skin), distraction of the patient’s attention, stimulation of the respiratory center (inhalation of carbon dioxide in its pure form or in the form of carbogen), lobelia, quinidine (as a decreaser in the excitability of the diaphragmatic muscle), alcoholism and, in extreme cases, transection phrenic nerve.

Tonic spasm of the diaphragm is observed with tetany, tetanus, and peritonitis. Therapy-chloroform, ether.

Diaphragmatic paralysis

Paralysis of the diaphragm is characterized by its high standing. When breathing, a divergence occurs towards the lower ribs, the epigastric region does not bulge, as is normal, and the liver does not descend. Shortness of breath develops during work and excitement. There is a change in voice, weakness of coughing, sneezing. Tension is released during defecation. With complete paralysis, minimal exertion may result in fatal asphyxia.

Diaphragmatic hernia (false and true). A diaphragmatic hernia is usually called a false traumatic hernia (hernia diaphragmatica spuria, traumatica; evisceratio), when in typical cases after a puncture wound or blunt trauma, as a rule, the stomach and intestines protrude into the chest cavity on the left through the gap in the diaphragm. Severe shortness of breath, vomiting, hiccups develop, and death from shock may even occur. The examination reveals tympanitis in the chest, absence of respiratory noise, displacement of the heart, especially characteristic iridescent bowel sounds in the chest or hemothorax, concomitant pleurisy, peritonitis, and sudden radiological changes.

A general practitioner more often deals with the long-term consequences of an injury, which the patient does not always find necessary to talk about without special questioning.

The patient usually experiences only nausea, vomiting, or symptoms of intestinal obstruction. There may be signs of compression of the mediastinal organs. When examining, it is important to pay attention to the wound scar. An unusual area of ​​tympanic sound is also found in the chest; respiratory mobility of the chest is limited (usually on the left), respiratory sounds are weakened or cannot be heard, the heart is displaced. Unlike pneumothorax, there is no bulging of the intercostal spaces, but a seemingly empty epigastric region is characteristic, especially the intestinal sounds of the prolapsed stomach and intestines heard near the hailstone. An X-ray examination after taking barium clarifies the picture in detail.

The most serious, sometimes fatal complication is intestinal obstruction. The treatment is surgical and technically difficult.

Less often emb. a true diaphragmatic hernia (hernia diaphragmatica vera) is given when, due to a congenital defect in the development of the diaphragm (usually behind the xiphoid process), the stomach or large intestine ends up in the anterior or posterior mediastinum, in a sac of one or all layers of the diaphragm.

In recent years, during a wide X-ray examination of patients, it is not so rare to find small diaphragmatic hernias at the hiatus oesophageus itself, with the upper part of the stomach protruding above the diaphragm. The patient presents vague dyspeptic complaints, and sometimes suffers from more severe reflex angina due to irritation of the nearby vagus nerve and coronary spasm. One should also distinguish from a diaphragmatic hernia the rare unilateral relaxation, relaxation or insufficiency of the diaphragm, which opens accidentally when, in the absence of complaints, tympanitis is found by percussion, and an x-ray examination reveals a high position of the diaphragm.

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Causes, symptoms and treatment of diaphragmatic hernia

The diaphragm is the main respiratory muscle in humans. If a hole or thinning of some area appears in it, and through it the abdominal organs penetrate or protrude into the chest cavity (less often, vice versa), this is a diaphragmatic hernia.

This hernia is dangerous because the intestines, stomach or esophagus that have penetrated into the chest cavity compresses and prevents the heart and lungs from working normally. Also, this position of the organs has a bad effect on the digestive organs themselves, since they are easily pinched in the tendon or muscle ring of the diaphragm through which they exited.

A diaphragmatic hernia can be acute or chronic. A chronic hernia may not bother the patient for a long time. Then the following symptoms occur (they are also signs of an acute hernia): chest pain, heartburn, belching, difficulty breathing, a burning sensation in the chest. These manifestations of the disease definitely prevent a person from leading a full life.

Diaphragm hernias of various types are a very common disease of the digestive system. It occurs in every tenth young person, and from the age of 50 it is found in every second. It is also diagnosed in 7–8% of people who complain of chest pain and cardiac dysfunction.

It is simple to cure such a hernia: the surgeon performs an operation in which the protruded organs are put back into place, and the diaphragm defect is sutured and strengthened. Medicines do not fight the problem, but only eliminate the symptoms and prevent complications of the disease.

What happens with a diaphragmatic hernia (anatomical information)

The diaphragm is a large parachute-shaped muscle that is located below the lungs and attaches to the costal arches. It has a peripheral muscle and a central tendon part. The vena cava passes through the tendon part to the heart, and in the muscular part there is an opening for the esophagus.

Click on photo to enlarge

The opening for the esophagus is the “weak spot” where diaphragmatic hernias most often form (they are also called hiatal or hiatal hernias). Through it, the esophagus, stomach, and sometimes the intestines exit into the chest cavity.

Normally, in a healthy person, the esophagus is secured by muscular and fibrous ligaments. But if muscle tone decreases, if the left lobe of the liver decreases (atrophies), or a person loses weight so much that the fatty tissue located under the diaphragm disappears, then the esophageal opening “stretches.” Because of this, the ligaments holding the esophagus weaken and the angle at which the esophagus enters the stomach increases (this causes the reflux of gastric contents upward).

The diaphragm is conventionally divided into three parts: lumbar, costal and sternal. In each of them, muscle fibers have their own direction. At the junction of these parts there are triangular sections that are quite pliable. This creates the conditions for the intestines to come out or protrude here. These are already different diaphragmatic hernias.

The structure of the diaphragm and muscles of the posterior abdominal wall.

Click on photo to enlarge.

Types and classification of hernias

There are two main types of diaphragmatic hernias: traumatic (develop under the influence of penetrating wounds and surgical interventions) and non-traumatic.

Each of this species is divided into two more subspecies:

True, when there is a hernial sac (that is, the protruding organs are wrapped in a thin film - peritoneum or pleura). This way, either a loop of intestine or a section of the stomach flowing into the duodenum, or both of them, can exit. These hernias can be strangulated.

False hernia - without a hernial sac. The gastrointestinal organs simply exit through the hole in the diaphragmatic muscle. This condition is possible for the esophagus or the initial parts of the stomach.

There are also non-traumatic hernias:

• congenital;
• neuropathic - caused by a violation of the nervous control of the diaphragm area, due to which this area is greatly relaxed;
• hernias of the natural openings of the diaphragm: esophagus, aorta and vena cava.

The symptoms of various types are not very specific, allowing a diagnosis to be made only by signs. To prescribe the correct treatment to a person, classification is needed.

Causes of the disease

Sports and industries where you need to lift weights

Connective tissue weakness (congenital or acquired)

Dystrophy of muscular-ligamentous structures

Long difficult labor

Age over 50

If at least one of these conditions is present, then diaphragmatic hernias very easily appear under the influence of provoking factors from the right column.

Diseases of the stomach and intestines

Diseases of the lungs and bronchi that cause frequent coughing

Ingestion of alcohol or chemical compounds that cause burns and scarring of the esophagus

Characteristic symptoms

The symptoms of a hernia will differ depending on whether it is a traumatic hernia or not.

Symptoms also depend on:

• whether the disease developed acutely (quickly),
• or the hernia penetrated from the abdominal cavity into the thoracic cavity for a long time (chronic course),
• or the hernia has been strangulated (compressed) in the hole from which it came out.

Acute diaphragmatic hernia most often manifests itself with the following symptoms:

• Chest pain that gets worse when coughing.
• Heartburn (feeling of heat behind the lower part of the sternum and acidic contents in the mouth). It intensifies when lying down, when bending forward or down. Heartburn also appears if you lie down immediately after eating.
• Belching with air or sour contents, which appears even during sleep and can be the cause of frequent bronchitis and pneumonia (due to food fragments entering the respiratory tract with air expelled from the stomach).
• Difficulty swallowing (a “lump” appears not in the throat, but in the sternum area) of liquid food, water; It is especially acute when eating in a hurry. In this case, solid food most often goes well.
• Bloating.
• Constant cough.
• Difficulty breathing (a person feels that he cannot “catch his breath” or that he does not have enough air).
• A burning sensation behind the sternum.
• Rapid heartbeat after eating.
• Rumbling or “gurgling” in the chest.

If a person has developed chronic diaphragmatic hernia, he does not feel anything for a long time. Subsequently, the same symptoms develop as in the acute version.

Symptoms of a strangulated diaphragmatic hernia:

severe pain in one half of the chest (most often in the left),

gases stop passing.

How to make a diagnosis

In order for the prescribed treatment to be adequate, it is necessary not only to make a diagnosis, but also to determine the type of hernia (which organs go through and where, whether there is a hernial sac or not). To do this, 4 examinations are prescribed:

X-ray examination of the chest and abdominal cavities. Before the procedure, you cannot eat for 6 hours, and 10–20 minutes before you need to drink a barium mixture, which you are given and asked to drink in front of the radiography room. This method allows you to monitor in real time the movement of barium through the esophagus into the stomach.

Fibrogastroscopy (FGDS) is a study in which the patient will need to swallow a special probe (tube) equipped with a camera at the end. The study is carried out on an empty stomach. Only according to FGDS the diagnosis of “hernia” is not made, but the degree of damage to the mucous membranes of the esophagus, stomach, and duodenum by hydrochloric acid is determined; establish the fact of bleeding from the vessels of the gastrointestinal tract located in the hernial sac.

pH-metry – measurement of acidity in the stomach and esophagus. The procedure is carried out using a thin probe.

If necessary, during FGDS a biopsy of the esophageal mucosa is performed.

If the doctor suspects a strangulated diaphragmatic hernia, an X-ray of the abdominal and chest cavities is performed without injecting barium. If the diagnosis is confirmed, the patient is prepared and operated on as an emergency.

X-ray of a patient with a hiatal hernia. The arrow indicates the part of the stomach that has penetrated into the chest

Hernia treatment methods

A diaphragmatic hernia can be completely cured only through surgery, especially if the hernia is true and can be strangulated at any time. But in 4 out of 10 cases, after such treatment, the hernia reappears, so the surgical method is rarely resorted to (2–15% of cases).

Conservative therapy is more often used (for example, due to contraindications or the patient’s disagreement with surgery).

Therapy without surgery

Conservative treatment does not cure diaphragmatic hernia, but it helps:

reduce the degree of reflux of gastric contents into the esophagus, and intestinal contents into the stomach;

reduce the acidity of gastric juice;

cure gastritis, ulcers;

start the normal direction of peristalsis (intestinal movements through which food moves).

Conservative treatment involves following a daily routine, diet and taking medications.

Diet

Meals should contain 1800–2000 kcal/day.

Six diet rules:

Eliminate simple carbohydrates (sweets, baked goods) and foods that cause fermentation (legumes, cabbage, carbonated drinks and beer) so as not to provoke the release of swollen intestinal loops or stomach into the chest cavity.

Remove acidic foods from your diet (sour juices, pomegranates, lemons, cherries, raw apples), which can aggravate the disease and provoke the development of ulcers or erosion of the mucous membrane of the stomach or esophagus.

Avoid foods that cause excessive secretion of gastric juice or pancreatic enzymes: smoked, fried, peppered foods, dishes with spices, pickled vegetables, barbecue.

Be sure to include in your diet foods that will make the intestines work and prevent the development of constipation: boiled beets, prunes, dried fruits.

It is useful to drink 100 ml of alkaline mineral water half an hour before meals: “Borjomi”, “Slavyanskaya”, “Polyana Kvasova”, “Jermuk”.

Eat small portions, often. Never go to bed after eating.

Based on reviews from people who used conservative treatment, they not only had to eat at least 3-4 hours before bed, but also slept only in a semi-sitting position, without leaning on pillows. To sleep, they either bought a functional bed with a headrest whose height could be changed, or placed 1-2 bricks at the head of the bed under the legs.

Medicines

Diaphragmatic hernia is treated with the following drugs:

(if the table is not completely visible, scroll to the right)

Reduces the production of gastric juice

No-shpa, riabal, papaverine, halidor

Eliminate hypertonicity of the muscles of the stomach and intestines, reduce pain

Drugs that reduce the production of hydrochloric acid

Ranitidine, famotidine, omeprazole, nolpaza

Reduces the synthesis of hydrochloric acid in gastric juice

Prevents the destructive effect of hydrochloric acid on the cells of the stomach or esophagus

Aluminum and magnesium preparations

Almagel, phosphalugel, Maalox

Neutralizes excess gastric acidity

Surgical intervention

This treatment, although it is the only “healing hernia”, is still rarely used: in 2–15% of cases due to frequent relapses of the disease. Surgery is absolutely indicated for ulcers of the esophagus that have led to either narrowing or bleeding.

Surgeons perform 3 types of operations:

Suturing the opening (hernial orifice), from which the organs emerge, with special sutures, followed by strengthening it with a polypropylene mesh.

Fixation of the stomach to the anterior wall of the abdomen after “putting it in place.”

Suturing the fundus of the stomach to the wall of the esophagus.

(the block below can be scrolled to the right to the end)

Diaphragmatic hernia: symptoms and treatment

Diaphragmatic hernia - main symptoms:

• Abdominal pain
• Fever
• Nausea
• Cardiopalmus
• Bloating
• Cough
• Chest pain
• Belching
• Burning behind the sternum
• Heartburn
• Anemia
• Stomach bleeding

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

Varieties

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

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

The third type is traumatic diaphragmatic hernia in children and adults. This pathology can be true or false, and it is associated with injuries that lead to the formation of holes in the anatomical septum. They speak of a true anomaly when the organs are located in the hernial sac in the area of ​​the pathological diaphragmatic opening, and a false one - when it is absent.

And finally, the last type is a hernia of the natural diaphragmatic opening. If there is tissue stretching in the area of ​​the natural opening of the esophagus, a hiatal or diaphragmatic hernia 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 arises as a result of genetic abnormalities in the fetus, and scientists cannot definitely establish the reason why such a defect occurs. Also, in older children, a diaphragmatic hernia may appear as a consequence of nervous disorders or as a consequence of certain chronic diseases, for example, chronic pancreatitis, cholecystitis and other pathologies.

If we talk about the development of the disease in adults, it should be noted that a hernia of the diaphragm is caused by:

• traumatic injuries (blunt abdominal injuries, chest bruises, knife wounds, etc.);
• disruption of innervation due to problems with the nervous system;
• conditions leading to a long-term increase in pressure in the abdominal cavity - prolonged labor, obesity, chronic constipation, heavy lifting, prolonged and debilitating cough and some others;
• disturbances in the tone of the anatomical septum that occur as a result of age-related changes in the body that appear in people after 50 years of age;
• chronic diseases of the gastrointestinal tract (peptic ulcer, esophagitis, pancreatitis 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 child’s lungs and heart, and an acquired one that occurs as a result of anatomical weakness of the diaphragm. The development of a disorder in the fetus occurs as a consequence 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 an unfavorable environmental situation, or works in a hazardous industry.

As mentioned above, children have a weaker diaphragm than adults, so they develop hernias several times more often. And in order to prevent the occurrence 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 development 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 thoracic region - be associated with diseases of the esophagus, stomach or duodenum. Moreover, if the hernia is small in size, there may be no symptoms at all - they appear only when it enlarges.

The first symptoms that the patient complains about are:

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

These symptoms are associated with disruption 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 hiatal or hiatus hernia include:

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

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

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

Note that patients often mistake the symptoms of a 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.

Diagnostics and treatment features

Abnormalities in the fetus can be diagnosed in the womb during an ultrasound examination. In children, diagnosis involves an X-ray examination with contrast, which allows one to see the protrusion of the esophagus or stomach through the hernial sac. In adults, diagnosis can be carried out using radiography and other methods, for example, fibroesophagogastroduodenoscopy (FEGDS). In addition, the acidity of the stomach and esophagus is examined, and its elevated levels give the doctor the opportunity to suspect this pathology.

This disease can be treated conservatively and surgically. The main method is surgical removal of the hernia, but 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 you treat the pathology conservatively, it is impossible to cure the patient - you can only reduce the symptoms, so conservative therapy is suitable in cases where the hernia is small, or it is used to prevent relapses of the pathology after surgical treatment.

Treatment of a diaphragmatic hernia involves proper nutrition and daily routine, as well as 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, treatment with folk remedies for this pathology is aimed at eliminating belching, heartburn, and constipation. Thus, the best folk remedies for heartburn are decoctions and infusions that use herbs such as chamomile, celandine, marshmallow root, and plantain. And peppermint and fennel fruits are good for bloating.

If you think that you have a diaphragmatic hernia and the symptoms characteristic of this disease, then a gastroenterologist can help you.

We also suggest using our online disease diagnostic service, which selects probable diseases based on the entered symptoms.

A bend in the gallbladder is an anomaly in the structure of this organ, during which deformation of the organ occurs. Against this background, there is a change in the normal shape of the gallbladder, which should have a pear-shaped appearance. In addition, there is a disruption in its functioning and stagnation of bile, which entails the development of complications.

Halitosis is characterized by a persistent unpleasant odor from the mouth, which cannot be eliminated with the help of traditional means of hygiene or prevention. The disorder is observed in both adults and children, regardless of age category.

Intestinal dysbiosis, based on the WHO assessment, is not actually a disease, so it would be more accurate to classify it as a syndrome. Intestinal dysbiosis, the symptoms of which arise against the background of an imbalance in the ratio of various microorganisms in the intestine, is, according to scientists, the result of various types of pathologies, but in no way their cause.

Gastroenterocolitis (foodborne toxic infection) is an inflammatory disease leading to damage to the gastrointestinal tract, localized mainly in the small or large intestine. It poses a great danger due to possible dehydration of the body if not sufficiently controlled. Characterized by a rapid onset and rapid progression. As a rule, by 3–4 days, if you follow the doctor’s recommendations and prescribe adequate treatment, the symptoms of the disease subside.

Esophageal ulcers are the process of ulceration of the inner wall of the esophagus due to the ingestion of gastric juice. In most cases, this disease is accompanied by peptic ulcers of the stomach and duodenum. As a rule, such formations in the gastrointestinal tract are single. However, there are clinical cases when there may be several such formations.

With the help of exercise and abstinence, most people can do without medicine.

Symptoms and treatment of human diseases

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Questions and suggestions:

Diaphragm diseases

Acute primary diaphragmatitis or Hedblom syndrome (Joannides-Hedblom syndrome) is extremely rare and is characterized by the formation of infiltrates in the diaphragm. The etiology of diaphragmatitis is unclear. With this disease, concomitant inflammation of the lung and diaphragmatic pleurisy are always diagnosed. It is believed that inflammation of adjacent organs is a secondary process.

Violation of the integrity of the diaphragm occurs as a result of injury from a firearm or bladed weapon, the end of a broken rib or chest injury, or a sudden sharp increase in intra-abdominal pressure. The possibility of damage to the diaphragm is indicated by the location of the wound (wound opening) below the level of the 6th rib. Closed injuries are observed during transport trauma, a fall from a height, and in some cases when lifting a heavy object, during childbirth, during severe vomiting and coughing (so-called spontaneous ruptures).