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HIATAL HERNIA TYPE OF HERNIA DIAPHRAGMATIC HERNIA

OVERVIEW

Congenital diaphragmatic hernia (CDH) is a congenital


Hiatal hernia is a condition in which the upper portion of the
stomach protrudes into the chest cavity through an opening of the malformation (birth defect) of the diaphragm. The most common
diaphragm called the esophageal hiatus. This opening usually is type of CDH is aBochdalek hernia; other types include Morgagni's
large enough to accommodate the esophagus alone. With hernia, diaphragm eventration and central tendon defects of the
weakening and enlargement however, the opening (or herniation) diaphragm. Malformation of the diaphragm allows
can allow upward passage or even entrapment of the upper the abdominal organs to push into the chest thereby impeding
stomach above the diaphragm. proper lung formation.
CDH is a life-threatening pathology in infants, and a major cause of
 Hiatal hernia is a common condition. By age 60, up to death due to two complications: pulmonary
60% of people have it to some degree. hypoplasia and pulmonary hypertension.[1] Experts disagree on the
relative importance of these two conditions, with some focusing on
 There are 2 types of hiatal hernia. hypoplasia, others on hypertension.[2] Newborns with CDH often
have severe respiratory distress which can be life-threatening
o The most common (95%), The sliding type, as unless treated appropriately.
its name implies, occurs when the junction between the
stomach and esophagus slides up through the esophageal Types of congenital diaphragmatic hernia
hiatus during moments of increased pressure in
the abdominal cavity. When the pressure is relieved, the Bochdalek hernia
stomach falls back down with gravity to its normal position.
The Bochdalek hernia, also known as a postero-lateral
o The fixed type (or paraesophageal) implies that diaphragmatic hernia, is the most common manifestation of CDH,
there is no sliding up and down. A portion of the stomach accounting for more than 95% of cases. In this instance the
remains stuck in the chest cavity. diaphragm abnormality is characterized by a hole in the postero-
lateral corner of the diaphragm which allows passage of the
abdominal viscera into the chest cavity. The majority of Bochdalek
hernias (80-85%) occur on the left side of the diaphragm, a large
proportion of the remaining cases occur on the right side, and a
small fraction are bilateral i.e., left and right sided defects. [3][5]
Morgagni's hernia
This rare anterior defect of the diaphragm is variably referred to as
Morgagni’s, retrosternal, or parasternal hernia. Accounting for
approximately 2% of all CDH cases, it is characterised by
herniation through the foramina of Morgagni which are located
immediately adjacent to the xiphoid process of the sternum.[3] The
majority of hernias occur on the right side of the body and are
generally asymptomatic; However newborns may present with
respiratory distress at birth similar to Bochdalek hernia.
Additionally, recurrent chest infections and gastrointestinal
symptoms have been reported in those with previously
undiagnosed Morgagni's hernia. In asymptomatic individuals
laparoscopic surgical repair is still recommended as they are at risk
of a strangulated intestine.

Diaphragm eventration

The diagnosis of congenital diaphragmatic eventration is used


when there is abnormal displacement (i.e. elevation) of part or all of
an otherwise intact diaphragm into the chest cavity. This rare type
of CDH occurs because in the region of eventration the diaphragm
is thinner, allowing the abdominal viscera to protrude upwards. This
thinning is thought to occur because of incomplete muscularisation
of the diaphragm, and can be found unilaterally or bilaterally.
[8]
 Minor forms of diaphragm eventration are asymptomatic,
however in severe cases infants will present with respiratory
distress similar to Bochdalek hernia

Hiatal Hernia
A diaphragmatic hernia is caused by the improper joining of CAUSES
structures during fetal development. As a result, the abdominal It involves three major defects.
organs such as the stomach, small intestine, spleen, part of the
liver, and the kidney appear in the chest cavity. The lung tissue  A failure of the diaphragm to completely close
on the affected side is thus not allowed to completely develop. during development.
Congenital diaphragmatic hernia is seen in 1 out of every 2,200 to  Herniation of the abdominal contents into the chest
5,000 live births. Most affect the left side. Having a parent or
sibling with the condition slightly increases your risk.  Pulmonary hypoplasia

The symptoms include acid reflux, and pain, similar to heartburn, CLINICAL Severe breathing difficulty usually develops shortly after the baby is
in the chest, and upper stomach. MANIFESTATION born, because of ineffective movement of the diaphragm and
In most patients, hiatus hernias cause no symptoms. Sometimes crowding of the lung tissue, which causes collapse. The reason
patients experience heartburn and regurgitation, when stomach why this occurs is not known.
acid refluxes back into the esophagus.
Other symptoms include:
 Bluish colored skin due to lack of oxygen
 Rapid breathing (tachypnea)

 Fast heart rate (tachycardia)


DIAGNOSTIC
Exams and Tests This condition can often be diagnosed before birth and fetal
EVALUATIONS
intervention can sometimes help, depending on the severity of the
A complete physical exam will focus on the
digestive, pulmonary (lungs), andcardiovascular (heart) systems. condition.[11] Infants born with diaphragmatic hernia experience
A rectal exam and stool test for blood may be necessary to respiratory failure due to both pulmonary hypertension and
determine if there is bleeding from the digestive tract. pulmonary hypoplasia. The first condition is a restriction of blood
 Initial tests  flow through the lungs thought to be caused by defects in the lung.
Pulmonary hypoplasia or decreased lung volume is directly related
o Electrocardiogram (ECG) to look for electrical to the abdominal organs presence in the chest cavity which causes
disturbances of the heart from disease 
the lungs to be severely undersized, especially on the side of the
o Chest x-ray to look for pneumonia, collapsed hernia.
lung, or other problems in the chest 
Survival rates for infants with this condition vary, but have generally
o Blood tests to look for anemia, infection, or
been increasing through advances in neonatal medicine. Work has
injury to the heart, pancreas, or liver 
been done to correlate survival rates to ultrasound measurements
o Other tests focusing on the cardiovascular and of the lung volume as compared to the baby's head circumference.
pulmonary organ systems if suspicion remains high for
problems in these areas This figure known as the lung to head ratio (LHR).

 Possible follow-up tests 


o Barium swallow or upper GI x-ray series may
be performed by aradiologist (you drinks some contrast
material, and x-rays are taken). 

 Medical treatment for hiatal hernia may include THERAPEUTIC A diaphragmatic hernia is an emergency that requires surgery.
prescription-strength antacids such MANAGEMENT Surgery is done to place the abdominal organs into the proper
as lansoprazole (Prevacid), omeprazole(Prilosec), position and repair the opening in the diaphragm.
or rabeprazole (Aciphex).
The infant will need breathing support until he or she recovers from
 Surgical treatments rarely are necessary or worth the surgery. Some infants are placed on a heart/lung bypass machine,
risk unless an emergency exists, such as a strangulated hiatal which gives the lungs a chance to recover and expand after
hernia. surgery.

o Endoscopy may be performed by If a diaphragmatic hernia is diagnosed during pregnancy (around


a gastroenterologist. A long fiberoptic scope is passed 24 to 28 weeks), fetal surgery may be considered.
through the mouth and into the stomach looking for an
ulcer, tumor, or other tissue damage. Sometimes
a biopsy is needed.
 - same nursing management.- NURSING 1. Assessment if the infant at birth is an integral component of
MANAGEMENT nursing care. This is accentuated in life- threatening cases
such as CDS, where prompt recognition of neonatal respiratiory
dustress, cyanosis, a scaphoid abdomen, and possible
mediastinal shift would alert the nurse to investigate further
evaluated for CDH; endotracheal intubation is an option for
providing adequate oxygenation until CDH is ruled out. If CDH
is diagnosed prenatally, and the infant is in distress,
endotracheal intubabation is required to prevent further
cumulation of air in the stomach and intestines and
subesequent respiratory compromise.
2. Perioperative care involves prompt recognition, resuscitation,
and stabilization of the infant, including ventilatory support,
blood gas monitoring, and administration IV fluids. Gastric
decompression is achieved with double lumen tube , and the
infant is observed for signs of impaired cardiac output, acidosis
and hypoxemia.
3. Postoperative care includes the routine observations discussed
in the care of the high-risk infant. Close observation to detect
signs of respiratory distress or fluid and electrolyte imbalances
is an important nursing function. The infant is closely monitored
for signs mediastinal shift, pulmonary air leak and infection.
Hypovolemia as a result of third- spacing of the intravascular
fluids may occur.
4. Aimed at reducing stimulation either from care activities such
as routine suctioning or from environmental factors such as
noise and light that further reduce infant stress, such as
management of pain, should be a routine aspect of care for the
infant with a CDH.
5. Because of the serious nature of the condition and the urgency
of treatment, the parents are in great need of ongoing support
and education regarding postoperative care. The infant with a
CDH may require long-term hospitalization and care. As soon
as medically possible, the parents should be involved in the
daily care of the child.

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