Diaphragmatic Hernia - Hiatal Hernia: Treatment And Surgery

2024 Author: Josephine Shorter | [email protected]. Last modified: 2024-01-07 17:49

Hernia of the esophageal opening of the diaphragm (diaphragmatic hernia)

Content:

• What is a diaphragmatic hernia?
• Symptoms of a hiatal hernia
• Reasons for the development of diaphragmatic hernias
• Congenital diaphragmatic hernia in children
• What can not be done with a diaphragmatic hernia of the esophagus?
• Treatment of hiatal hernia
• Diet for a hernia of the diaphragm

Diaphragmatic hernia occurs due to the displacement of part of the esophagus into the chest cavity through the opening of the diaphragm. The incidence is 2% of all cases of hernia, diagnosed after X-ray examination. In 5% of cases, a hiatal hernia is detected when patients go to the doctor with complaints of gastrointestinal disorders.

Most often, a diaphragmatic hernia is asymptomatic, however, patients may show signs of gastroesophageal reflux disease, heartburn, acid reflex, chest pain (See also: Causes and symptoms of heartburn, how to get rid of heartburn?)

What is a diaphragmatic hernia?

The diaphragm separates the chest and abdominal cavities, consists of muscles, and attaches to the spinal column and ribs. The central part consists almost entirely of connective tissue, contains few muscle fibers and normally forms a dome, bending towards the chest cavity.

From the side of the spine, vessels and the esophagus pass through the diaphragm, for which there are holes in it through which protrusion of internal organs and the formation of a hernia can occur.

If part of the stomach exits through the diaphragmatic orifice, the esophageal valve, which separates the contents of the esophagus and stomach, may malfunction. As a result, the acidic contents of the stomach can enter the esophagus, damaging its mucous membrane and provoking the development of esophagitis and other pathologies of the gastrointestinal tract, the symptoms of which are often manifested in diaphragmatic hernia.

Symptoms of a hiatal hernia

With diaphragmatic hernias of a small size, clinical symptoms may not be at all.

If the upper part of the stomach has entered the diaphragmatic opening, then the following symptoms may be observed:

• Heartburn after every meal or with sudden changes in body posture, while bending forward;
• Pain in the lower third of the sternum or hypochondrium;
• Pain in the region of the heart, characteristic of coronary heart disease, radiating to the left shoulder and scapula, which stop after a nitroglycerin tablet. In this case, the ECG does not show violations of cardiac activity;

Complications of a hiatal hernia make themselves felt by a number of symptoms that arise from solaritis, perivisceritis and compression of the hernial sac:

• Subfebrile fever and pain in the xiphoid disorder of the sternum are characteristic of perivisceritis;
• Epigastralgia, aggravated by pressure in the solar plexus region, is less pronounced when bending forward - signs of solaritis;
• Dull pain in the epigastric region and behind the sternum, swallowing air and belching appear when the hernial sac is squeezed.

Other symptoms of hernia complications:

• Dull chest pain or tingling in the sternum;
• Frequent belching of air or stomach contents, after which a sour taste appears in the mouth;
• Signs of stomach dyspepsia, impaired digestion (See also: Causes and symptoms of dyspepsia);
• Intestinal disorders, symptoms characteristic of intestinal diverticulosis and duodenal ulcer;

• Symptoms of inflammation of the pancreas and gallbladder; girdle pain, characteristic of pancreatitis, may occur; (See also: Pancreatitis - how does it manifest? What to do with an attack of pancreatitis?)
• Heart rhythm disorders - tachycardia, extrasystole; in some cases, the patient can be treated for a long time and unsuccessfully by a cardiologist with an erroneous diagnosis of angina pectoris or ischemic heart disease.

In half of cases, a hernia of the diaphragm is asymptomatic, 30% of patients go to the doctor because of the symptoms of heart pathology caused by complications of the disease, and in 5-7% of cases, the hernia is diagnosed after an X-ray examination of patients with complaints of gastric disorders.

For the differential diagnosis of a hernia of the diaphragmatic opening of the esophagus, the following symptoms are important:

• Pain after a heavy meal or during physical exertion, aggravated by bending the body and coughing;
• The pain often manifests itself in a horizontal position of the body, disappears after vomiting and belching, moving to an upright position, a sip of water or a deep breath;
• Chest pain is often dull and moderate, rather than sharp and severe.

The causes of pain in a hernia of the diaphragm are compression of the nerves and vessels of the stomach when its cardial part enters the chest cavity, the effect of the acidic contents of the intestine and stomach on the esophageal mucosa and stretching of its walls.

Reasons for the development of diaphragmatic hernias

The esophagus passes through the diaphragm through its esophageal opening, at the place where it passes there is a thin membrane of connective tissue that separates the two cavities - the chest and abdominal. In the abdominal cavity, the pressure is greater than in the chest, but normally the membrane withstands it, and only with dystrophic changes or congenital weakness of the connective tissues does it stretch and part of the stomach or other parts of the esophagus is displaced into the chest cavity.

The mechanism of development of a hiatal hernia is triggered by a combination of two factors - weakness of the connective tissues and increased intra-abdominal pressure. In addition, with dyskinesia of the digestive tract, traction of the esophagus may occur - it is pulled up and, with insufficiently developed connective tissues of the diaphragm, it can provoke the formation of a hernia.

Factors provoking a hernia of the diaphragm:

• Weakness of the connective tissue that strengthens the diaphragmatic opening. The ligaments and connective tissues that strengthen the esophagus can weaken with age, losing their elasticity. Therefore, a hernia of the diaphragm most often occurs in elderly patients over the age of sixty. In addition, the disease develops in people with flat feet and Marfan syndrome, with underdeveloped connective tissues from birth.
• Chronically increased intra-abdominal pressure. A number of factors can provoke increased pressure in the abdominal cavity: flatulence, constipation, chronic cough, excessive physical exertion. Increased intra-abdominal pressure cannot provoke a hernia of the diaphragm by itself, but if the ligaments are not strong enough, then under the pressure of internal organs they can be deformed, the abdominal esophagus exits through the diaphragmatic opening with the formation of a hernial sac. In 50% of patients with chronic bronchitis, which manifests itself as a persistent cough, a hernia of the diaphragm of varying severity was found. Other causes of increased pressure in the abdominal cavity are pregnancy, frequent vomiting, large neoplasms, and overweight.
• Traction of the esophagus in concomitant diseases of the digestive tract. Functional disorders of the digestive system contribute to the development of hypermotor dyskinesia, pathology often develops with gastric and intestinal ulcers, inflammatory diseases of the gallbladder and pancreas. Longitudinal contractions of the esophagus during dyskinesia can pull it upward, creating a load on the connective tissues of the diaphragmatic opening. The traction of the esophagus is also provoked by inflammatory and cicatricial processes in its mucosa, as a result of which it is shortened, pulling up. If the tissues in the area of the diaphragmatic opening are not elastic enough, the digestive tract organs exit into the chest cavity.

Congenital diaphragmatic hernia in children

Congenital hernia of the diaphragm is a severe surgical pathology in which newborns have a serious health condition with a threat to life. Prenatal diagnosis allows you to identify the disease in the perinatal period and provide timely medical care to the child immediately after delivery. For this, a pregnant woman is placed in a specialized center.

There are three forms of congenital diaphragmatic hernia - anterior hernia, hiatal hernia, and diaphragmatic hernia:

1. Anterior hernias are quite rare, their manifestations are noticeable already in the first month of a child's life.
2. Hernia of the esophageal opening of the diaphragm is divided into true and false.
3. For a true hernia, the formation of a hernial sac is characteristic, while with a false hernia it is not.

Children with a false form of diaphragmatic hernia often die even in the hospital, since the organs of the chest cavity are underdeveloped and cannot fully function. This is due to the release of the abdominal organs into the chest cavity even during gestation. The stomach, intestines, spleen and, in some cases, the left side of the liver are displaced into the chest and compress its organs.

The causes of this pathology may be excessive physical exertion that a woman was subjected to during pregnancy, chronic diseases of the respiratory system, smoking and other bad habits, and malnutrition.

Symptoms of a congenital hernia of the diaphragm may be mild if the size of the defect is small. Only a few years later, the child complains of stomach pain, intestinal upset, heartburn and constant belching after eating.

With a significant defect, the child may have blood in the stool, lack of appetite, vomiting, swelling of the chest with a sunken abdomen, cyanosis of the skin.

Prenatal diagnosis

Ultrasound examination shows an abnormal location of the organs of the chest cavity, which requires further diagnosis by echography. Echography gives more detailed information about the organs of the chest, if anechoic formations are present in this area, then the doctor may suspect the exit of the stomach, intestinal loops or the left lobe of the liver through the diaphragmatic opening. Echography allows you to detect another sign of a diaphragmatic hernia - displacement of the heart to the right, but this symptom is not very pronounced in children in the perinatal period. It is very difficult to detect a bilateral hernia of the diaphragm at this stage, often the disease is diagnosed only after childbirth.

Prenatal diagnosis allows you to take all the necessary measures to save the child's life during childbirth. Children with congenital hernia of the diaphragm often die in the hospital, since this pathology interferes with the full formation of internal organs during the perinatal period.

A diaphragmatic hernia can be detected already in the first trimester of pregnancy, the earliest detection period is 12 weeks, but in most cases, the pathology is detected at 26-27 weeks, which is associated with low quality equipment and a lack of qualified specialists.

Another prenatal diagnostic technique that is used in conjunction with echography is perinatal karyotyping. It provides information on the degree of risk of developing congenital pathologies and hereditary diseases in a child.

What can not be done with a diaphragmatic hernia of the esophagus?

The rules of behavior for a patient with a diaphragmatic hernia should exclude the influence of factors that cause an increase in intra-abdominal pressure in order to prevent further displacement of organs into the chest cavity and the progression of the disease:

• Patients are advised to follow a special diet that excludes foods that cause intestinal irritation;
• Take food in fractional portions every few hours;
• Avoid bending the body forward, sudden changes in body position - this can cause pain in the sternum and heartburn;
• You cannot tighten the belt tightly, wear clothes that compress the stomach - this creates additional pressure in the abdominal cavity;
• Avoid heavy physical exertion, but at the same time regularly perform physiotherapy exercises that strengthen the muscle corset and restore the tone of the diaphragm;
• Normalize stool - constipation and diarrhea increase intra-abdominal pressure and promote hiatal hernia.
• It is recommended to drink a teaspoon of unrefined vegetable oil before and after meals;
• Pain and heartburn with a diaphragmatic hernia increases at night and becomes more pronounced when the body is moved to a horizontal position, therefore, before resting, you must refrain from eating - the last intake at least three hours before bedtime.

Prohibited foods for a hernia of the diaphragm:

• Alcohol and drinks containing caffeine - tea, coffee, soda;
• Smoked meats, pickled foods, hot spices;
• Fermented milk products (keep the amount to a minimum) and sour fruit juices;
• Peas;
• Fresh bread and pastries - can be eaten dried.

Alkaline mineral waters, such as Borjomi, help to remove the manifestations of heartburn and restore the acid-base balance in the esophagus. The drug used to neutralize gastric juice in diaphragmatic hernia is almagel. They drink it on an empty stomach, 20-30 minutes before a meal, two teaspoons at a time. Regular intake of the drug allows you to neutralize the negative effects of gastric juice on the walls of the esophagus and prevent the development of complications of diaphragmatic hernia.

Treatment of hiatal hernia

The most common symptom of a hiatal hernia (occurs in 98% of cases) is chest pain, usually dull and prolonged, rarely severe and intense. The main distinguishing characteristic is the strengthening when changing the body posture, tilting forward, moving to a horizontal position.

Belching with acidic contents of the stomach, after which there is a specific taste and burning sensation in the mouth, as well as regurgitation of air, is another common (42%) symptom of diaphragmatic hernia.

Dysphagia or difficulty in swallowing, which is often aggravated by eating very hot or cold food, is observed in 31% of patients with a hernia of the diaphragm. Dysphagia can manifest itself with hasty consumption of food, insufficient chewing. This symptom occurs due to inflammation of the esophagus, into which the contents of the stomach enter due to functional insufficiency of the cardia. Dysphagia indicates the development of a complication of a hernia of the diaphragm - esophagitis.

Burning in the sternum, heartburn after a heavy meal, worse at night? also refer to the characteristic symptoms of a diaphragmatic hernia.

Timely diagnosis and treatment of hiatal hernia are necessary to avoid dangerous complications of the disease - stomach and intestinal ulcer, bleeding of the part of the stomach that has entered the hernial sac, gastroesophageal reflux disease, esophagitis, shortening of the esophagus and inflammatory cicatricial processes.

There are two main approaches to the treatment of hiatal hernia - conservative therapy and surgical treatment.

Conservative treatment of hiatal hernia

Conservative therapy does not imply a complete correction of the hernia, but mitigates its negative manifestations and is the prevention of complications from the digestive tract, in particular, it improves the condition of the patient with reflux esophagitis.

Conservative therapy is aimed at reducing the inflammatory process, preventing dyskinesia of the esophagus and stomach, which can provoke traction of the esophagus, as well as normalizing intra-abdominal pressure. Conservative treatment helps to normalize the tone of the pylorus, restore the function of the valve that separates the passage of the esophagus into the stomach. In the conservative therapy of diaphragmatic hernia, it is not drugs that come to the fore, but a set of therapeutic measures and rules that the patient must follow.

The therapeutic measures include a special diet, the purpose of which is to reduce the load on the digestive organs, avoid irritation of the intestines and increase the secretory activity of the stomach, as well as weight loss, since obesity is one of the factors that increase intra-abdominal pressure. Rejection of bad habits, adherence to the rules of a healthy lifestyle, limitation of physical activity are important components of conservative therapy for diaphragmatic hernia.

Medicines that are used in the conservative treatment of hernia are designed to reduce the acidity of the stomach so that when its contents enter the esophagus, damage to its mucosa does not occur. These include alkaline mineral waters, anticholinergics (atropine, platifillin) and antispasmodic drugs (noshpa, papaverine).

Other medicines have an astringent effect, prevent inflammatory processes - these are solutions of burnt magnesia, bismuth nitrate, silver.

As part of the conservative treatment of hiatal hernia, antihistamines, neuroleptic and sedatives are used, physiotherapy is carried out using novocaine in the epigastric region.

If all of the above methods are ineffective, then the patient is prepared for surgical treatment, which allows you to completely eliminate the pathology.

Removal of hernia of the diaphragm

Surgical removal of a hernia is performed only in 10% of cases, for this there are the following indications:

• The size of the hernia is very large, under its pressure, lung function and cardiac activity are impaired;
• The hernia of the diaphragm provoked an anemic state in the patient;
• Hernia symptoms cannot be corrected with a therapeutic diet and medication;
• Against the background of a diaphragmatic hernia, the patient developed gastric or intestinal ulcer, esophagitis, and damage to the esophagus.

The operation consists in pulling the stomach and esophagus from the chest cavity, where they were displaced, into the abdominal cavity, after which the hernial orifice (diaphragm defect) is strengthened with special methods.

The two main tasks of the surgical treatment of a hernia of the diaphragm are the elimination of the hernial orifice and the creation of an antireflux barrier. Reflux disease develops due to dysfunction of the cardia - a valve that blocks the entrance to the stomach. When part of the esophagus is displaced through the diaphragmatic opening into the chest cavity, the activity of the cardia is disrupted, the contents of the stomach enter the esophagus, irritating its mucous membrane and causing inflammatory processes, esophagitis develops. During the operation, the stomach is returned to the anatomically correct position, bringing it down into the abdominal cavity, after which the phrenic-esophageal ligament is strengthened.

There are two methods of surgery used to remove a hernia and restore the functionality of the cardia - laparotomy and thoracotomy:

• Laparotomy - an operation during which access is provided transabdominally (through the peritoneal approach),
• Thoracotomy - an operation during which access is provided from the side of the chest - is used if a diaphragmatic hernia provoked pathologies of the respiratory and cardiac systems.

Also distinguish:

• Transabdominal operations are easier for patients to tolerate (this is important to consider, since diaphragmatic hernia in most cases affects elderly people), while the severity of pain after surgery is minimized. Another important advantage of this operation is the ability not only to eliminate a hernia, but also to perform surgical treatment of other pathologies of the digestive tract - gallstone disease, tumors and duodenal ulcers.
• Transthoracic operations are characterized by a longer rehabilitation period, during which severe pain can occur. However, thoracic access is necessary if, due to hernia and scarring, the esophagus is shortened and pulled up (traction).

Four groups of operations used for the surgical treatment of diaphragmatic hernia:

• Strengthening the phrenic-esophageal ligament and reducing the defect in the diaphragm;
• Operations aimed at restoring the physiological angle of His;
• Fundoplications - are used to correct such complications of diaphragmatic hernia as esophagitis, prevent the development of reflux disease with minimizing the risk of recurrence of the disease;
• Gastrocardiopexy - the esophagus and stomach are fixed on the subphrenic structures, restoring the function of the cardia, which also helps to prevent reflux disease.

Diet for a hernia of the diaphragm

Diet for diaphragmatic hernia is an important measure on which the successful treatment of the disease depends. The diet for this diet is designed in such a way as to fully supply the patient's body with the nutrients necessary for tissue regeneration, but at the same time not cause irritation to the intestines and increased gastric secretion.

The secretory activity of the stomach increases after eating certain foods (spicy, salty, smoked and fried foods, red pepper, alcohol and sweet soda). With a hernia of the esophageal opening of the diaphragm, the function of the valve, which separates the contents of the stomach, is disrupted, as a result of which gastric juice with concentrated acid can enter the esophagus, injuring its mucous membrane. This provokes heartburn, nausea and belching after eating, and in the long term it can contribute to the development of complications of diaphragmatic hernia, provoke esophagitis.

The principles of building a diet for a hernia of the diaphragm:

• Fast-digesting, protein-rich food that does not overload the stomach;
• Products are subjected to thermal and mechanical processing, dishes must have a liquid, homogeneous consistency (liquid cereals, soups-purees, soufflés);
• Drink plenty of 7-8 glasses of water a day, mineral water with slightly alkaline properties;
• Follow a diet without skipping meals, as this can cause bloating and nausea;
• The daily ration is divided into 6 small portions, the last of which should be taken four hours before bedtime.

Fried, salty, sour, spicy and any foods that can cause irritation of the intestines and increased secretion of gastric juice are excluded from the diet, including those for which the patient has an individual sensitivity.

Food should be taken in small portions, breaking its amount not three, but into five or six meals a day. This is necessary so as not to create unnecessary stress on the stomach and digestive organs, not to cause an increase in intra-abdominal pressure, which contributes to an increase in hernia.

The last meal is carried out no later than four hours before going to bed. In the first half of the day, it is advisable to refrain from eating such products: milk and dairy products, fresh cabbage, legumes, corn. The use of legumes - peas and beans - is best kept to a minimum or completely eliminated from the diet. In addition, foods to which the patient has increased sensitivity are removed from the diet - after taking it, heartburn, belching, flatulence and bloating occur.

Drinking plenty of fluids is an important part of the diet for patients with a hernia of the diaphragm. It is recommended to drink eight glasses of pure mineral water a day; the mineral waters Essentuki-17 and Borjomi are best suited for this.

Immediately after eating, one should not engage in physical exercises and expose the body to stress, however, lying is also not recommended - in a horizontal position, the patient often develops heartburn, since the contents of the stomach pass into the esophagus.

The patient's diet should be rich in proteins and essential fatty acids, for which it includes boiled chicken or beef, fish, eggs and cottage cheese, as well as vegetable oils - sunflower, flaxseed, sea buckthorn and fish oil, which are drunk a spoonful a day before meals.

Almost everything is allowed from cereals, except for rice. When cooking porridge, you need to take one and a half times more water than usual, so that it turns out to be very soft and boiled. If the porridge is not soft and homogeneous enough, it is additionally chopped in a blender. It is also advisable to use other products in chopped form - the meat is ground into minced meat and used to make cutlets and meatballs, and the fish is served as a soufflé. Steam or boil, fried food is completely excluded from the diet.

It is forbidden to use seasonings and sugar in dishes for patients with a hernia of the diaphragmatic opening, as this provokes increased acidity of gastric juice and creates risks for trauma to the esophagus.

Traditional medicine recommends drinking decoctions of meadowsweet, sweet hernia and cinquefoil goose to alleviate the symptoms of a hiatal hernia.

Fruits permissible in the patient's diet - pears, bananas, peaches, apples, can be eaten baked and without a peel, since fresh they are quite acidic and stimulate the secretory activity of the stomach.

With congenital diaphragmatic hernia discovered during prenatal diagnosis, the diet for the pregnant mother is prescribed by a nutritionist in conjunction with an obstetrician.

The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist

Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.