DIAPHRAGM AND DIAPHRAGM AND HIATUS HERNIAHIATUS HERNIA
Anatomy of diaphragm
Diaphragm Diaphragmatic
communications
Physiology
Normal anatomy of LES
Normal anatomy of LES
Normal anatomy of LES
Hernia-peritoneum diverticulum
Clasification
Congenital Accuired
Congenital herniaCongenital hernia
Congenital diaphragmatic hernia
Incidence
1 : 2000-5000 live birth 8 % of all major congenital anomalies mortality rate nearing 70 percent CDH accounts > 1% of total infant
mortality in USA
Cost per new case CDH = 250 000 $
Diaphragm Development
Causes The cause of CDH is largely unknown CDH can occur as part of a multiple
malformation syndrome Karyotype abnormalities have been reported in
4% of infants with CDH
Congenital Diaphragmatic Hernias (CDH)
Types of Congenital Diaphragmatic Hernias (CDH)
– Bochdalek – Morgagni– Diaphragmatic eventration– Central tendon defects
Bochdalek Hernia
Postero-lateral diaphragmatic hernia Most common manifestation of CDH,
accounting for more than 95% of cases Majority of Bochdalek hernias (80-85%)
occur on the left side of the diaphragm– A failure of the diaphragm to completely close
during development.– Herniation of the abdominal contents into the
chest– Pulmonary hypoplasia
Morgagni Hernia anterior defect of the diaphragm referred to as Morgagni’s, retrosternal, or
parasternal hernia accounts for approximately 2% of all CDH cases characterized by herniation through the foramina
of Morgagni which are located immediately adjacent to the xyphoid process of the sternum
majority occur on the right side of the body and are generally asymptomatic
Diaphragmatic eventration
abnormal displacement (i.e. elevation) of part or all of an otherwise intact diaphragm into the chest cavity
diaphragm is thinner in the region of eventration, allowing the abdominal viscera to protrude upwards
thinning is thought to occur because of incomplete muscularisation of the diaphragm
Minor forms of diaphragm eventration are asymptomatic
Congenital Diaphragmatic Hernias (CDH)
Left sided CDH is a 2 - 4 cm postero-lateral defect
Right lobe of liver can occupy most of hemithorax in rt side defect
Hepatic veins may drain ectopically into right atrium
Lung and liver may be fused
Prenatal Diagnosis ultrasonography diagnosis (as early as the second
trimester)
Mediastinal shuntViscera herniation (stomach, intestines, liver*, kidneys, spleen and gall
bladder) Abnormal position of certain viscera inside the abdomenStomach visualization out of its usual positionIntrauterine growth retardation*Polyhydramnios*Fetal hydrops*
* bad prognosis* bad prognosis
Fetal diafragmatic hernia: Ultrasound diagnosis
Prenatal MR Imaging - single-shot turbo spin-echo (HASTE)- of congenital diaphragmatic hernia
Prenatal MR Imaging of congenital diaphragmatic hernia
Pulmonary hypoplasia
Anatomopathology show of CDH
Prenatal Counseling multidisciplinary team patient's obstetrician perinatologist geneticist surgeon social worker
Prenatal management
Glucocorticoids Thyrotropin-releasing hormone Fetal surgical therapy (Antenatal surgical intervention,
In utero tracheal occlusion )
Delivery Room Management affected infants should be delivered in a specialized
center require positive pressure ventilation in the delivery
room. to prevent distension of the gastrointestinal tract and
further compression of the pulmonary parenchyma, a double-lumen nasogastric or orogastric tube of large caliber is placed to act as a vent.
early intubation
Postnanal Diagnosis
Respiratory distress Scaphoid abdomen Auscultation of the lungs reveals poor air
entry Shift of the heart to the side opposite
Postnanal Diagnosis left-sided CDH
Radiograph in a male neonate shows the tip (large arrow) of the nasogastric tube positioned in the left hemithorax. Note the marked apex leftward angulation of the umbilical venous catheter (small arrow).
Right congenital diaphragmatic hernia
Radiograph in a male neonate shows that the nasogastric tube (arrow) deviates to the left of the thoracic vertebral bodies as it passes through the inferior portion of the thorax
Postnatal management
Mechanical ventilation Nitric Oxide Surfactant Surgery
Operative approach
The defect in the diaphragm
Patch repair of a large defect
Evolving Therapies
In utero repairLiquid ventilationPulmonary transplantationPharmacology
– Prostacyclin derivatives– Calcium channel blockers– Phosphodiesterase inhibitors
Pulmonary recovery: When all resources, are provided, survival rates range from 40-69%.
Long-term morbidity: Significant long-term morbidity, including chronic lung disease, growth failure, gastroesophageal reflux, and neurodevelopmental delay, may occur in survivors.
Prognosis
ADULT ADULT DIAPHRAGMATIC DIAPHRAGMATIC HERNIAHERNIA
Classification
?Asymptomatic congenital diaphragmatic hernia
Posttraumatic or postoperative Hiatus hernia
Posttraumatic hernia
Symptoms
Uncomplicated:– Similar woth GERD– Respiratory symptoms– Cardiac arrhythmia, ischemic heart disease\
Complications:– Strangulation: acute respiratory and digestive
symptoms, very difficult to assess on clinical examination
Diagnostic Plain thoracic X-Ray Nasogastric tube + X-ray Barium or Gastrographin studies if non-
emergency CT-scan
Treatment Approach:
– Laparotomy vs laparoscopy– Thoracotomy vs thoracoscopy– Urgent vs chronic disease
Reintegration of viscus Resection of peritoneal sac Close the defect in diaphragm
– Suturing– Mesh
HIATAL HERNIAHIATAL HERNIA
Hiatal Hernia Defined (Also called Diaphragmatic Hernias)
Protrusion of the stomach upward into the mediastinal cavity through the esophageal hiatus of the diaphragm– Sliding
• 90% of cases – Rolling (paraesophageal)
Sliding Hiatal Hernia The esophagus passes
through the diaphragm and connects to the stomach. When a sliding hiatal hernia is present, part of the stomach moves up through an opening (hiatus) in the diaphragm. The presence of a hiatal hernia increases the risk for gastroesophageal reflux
Paraesophageal Hiatal Hernia The fundus and
possibly portions of the stomach’s greater curvature, rolls through the esophageal hiatus and into the thorax beside the esophagus
A Comparison of the normal stomach, sliding hiatal hernia and rolling hiatal hernia
Diagnostic Tools Barium Swallow CXR Endoscopy with biopsy Stool for quiac Esophageal manometry
Diagnostic Tools
Key Features of Hernias Sliding hiatal
hernia– Heartburn– Regurgitation– Chest pain– Dysphagia– Belching
Paraesophageal hernia– Feeling of fullness
and breathlessness after eating
– Feeling of suffocation
– Cheat pain that mimics angina
– Symptoms worse in recumbent position
Symptoms
Complications
– Slow bleed– Anemia– Pulmonary Aspiration
Risk Factors Increased intra-
abdominal pressure– Obesity– Pregnancy– Bending– Coughing– Weight lifting
Age
Medical Treatment Goals
– Aimed at relieving symptoms and prevent complications• Bleeding
– Reduce regurgitation of stomach contents into esophagus• Medications
– Includes antacids and histamine receptor antagonists (Pepcid and Reglan)
– Neutralizes stomach acidity– Decrease acid production
Surgical Intervention Used when medical therapy fails to
control symptoms Surgery is extensive and produces
frequent complications Hiatal hernia tends to recur after surgery
– Laparoscopic Nissen Fundoplication
Postoperative Care Risk for bleeding, infection and organ
injury Respiratory Care NG tube Management Nutritional Care
Results
Complications Temporary dysphagia Gas bloat syndrome (avoid carbonated
beverages) Atelectasis, pneumonia Obstructed NG tub Reccurrent GERDe RARE:
– Mediastinitis– Fistula
Complications