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Topic - Diaphragmatic Hernias
Topic - Diaphragmatic Hernias
Pathology
As well as any hernia, diaphragmatic has hernial ring, hernial sac and hernial content.
The tissues in the region of hilus, due to tension and pressure, result in atrophy and sclerosis.
necrosis, chronic inflammation, adhesions of the hernial content can develop.
Classification
There are such types of hernia:
1) congenital;
2) acquired;
3) posttraumatic;
4) true;
5) false.
А. Diaphragmatic hernia.
I. Sliding (axial) diaphragmatic hernia:
1) esophageal;
2) cardial;
3) cardiofundal.
ІІ. Diaphragmatic hernia of paraesophageal type:
1) fundal;
2) antral;
3) intestinal (small and large intestine);
4) combined intestinal-gastric hernias;
5) epiploic.
ІІІ. Huge diaphragmatic hernia:
1) subtotal gastric;
2) total gastric.
ІV. A short esophagus:
1) acquired short esophagus;
2) congenital short esophagus (thoracic stomach).
B. Parasternal hernias:
1) retrosternal;
2) retrocostosternal.
C. Lumbocostal diaphragmatic hernias.
D. Hernia of atypical localization.
Sliding (axial)
Paraesophageal
Esophageal hernias:
Esophageal
Cardiofundal
Mixed paraesophageal
Paraesophageal fundal
Paraesophageal hernia
Mixed hernia
Differential diagnostics
Stenocardia. Diaphragmatic hernias frequently cause the pain, which character not only
the patient, but also doctor can identify as anginal. However in diaphragmatic hernia the pain
more often is vague, spread to the stomach region and depends on body position. The pain, as a
rule, arises in supine position and disappears, if the patient upward. More often it spreads to the
right and anginal vice versa to the left. In diaphragmatic hernia the ECG can manifest the
coronary failure, nevertheless standing up, owing to the stop of strangulation leads to
disappearance of these pathological sings. The pain caused by diaphragmatic hernia does not
relieve after nitroglycerin. In this case more effective and prompt is atropine.
Peptic ulcer. The pain in gastric and duodenal ulcer frequently localized in epigastric
region with irradiation in the left or right hypochondrium. Nevertheless, it is characterized by
periodicity, which caused by meal and disappears after the usage of soda.
Lung atelectasis, pleurisy, pneumonia are also should be differentiated with
diaphragmatic hernia. Thus it is always necessary to remember, that the extrapulmonary shadow
of supradiaphragmatic disposed hernia on a plain roentgenogram can resemble intrapulmonary.
For correct diagnosis it is possible to recommend polypositional X-radiography, contrast
roentgenography of esophagus and stomach.
Hypochromic anemia frequently associated due to repeated or permanent small
bleedings. They are caused by a regional destruction a gastric mucosa. In the females of senior
age if it is fail to explain genesis of the revealed anemia, it is necessary to think about the
opportunity of diaphragmatic hernia and carry out appropriate X-ray examination.
Steps of cruroplastic
DIAPHRAGMATIC RELAXATION (DIAPHRAGMATIC EVENTRATION)
The term "diaphragmatic relaxation " was used for the first time in 1906 by Witting. It means a
relaxation of diaphragm, its high standing and displacement upward of abdominal organs.
The term ‘diaphragmatic eventration’ is used in common practice to describe a condition of
relaxation of the diaphragmatic dome. It may present at birth as a congenital condition due to a
defect of diaphragmatic development or in a later stage of life as an acquired condition
(‘acquired diaphragmatic paralysis’ or ‘acquired diaphragmatic elevation’).
Pathology
In congenital form of a diaphragmatic relaxation revealed muscular aplasia, in acquired –
atrophy of muscular fibers.
Classification
1) Complete: left-side, right-side;
2) Incomplete: anterior, posterior, restricted (partial).
Diaphragmatic relaxation
Variants of clinical course and complications
Asymptomatic course of diaphragmatic relaxation in the majority of patients has caused
interpretation of this pathology as "innocent disease". Nevertheless the shift and rotation of heart
can cause the heart failures, and the restriction of pulmonary excursion sometimes leads to
chronic pneumonia. The gastric inflection frequently may result in disturbance of the valvular
mechanism of esophagogastric junction and occurrence of reflux esophagitis.
Differential diagnostics
Diaphragmatic elevation is the secondary high standing, which can arise as a result of
ascites, pregnancy, expressed meteorism, peritonitis, tumours of abdomen, splenomegaly or
megacolon.
Pneumothorax, pyopneumothorax, pleurisy. Such misdiagnostics in the patients with
diaphragmatic relaxation frequently caused by chest pain, cough, dullness and tympanic sound
revealed at percussion, and weak breathing at auscultation. Chest X-radiography rather
contributes to exact diagnostics.
Diaphragmatic hernia. The differential diagnosis of diaphragmatic relaxation with this
pathology is the most difficult. Nevertheless it has the important practical value, because the
threat of strangulation of diaphragmatic hernia requires an active surgical tactics. During the
establishment of the diagnosis it is always necessary to remember, that clinical manifestation of
diaphragmatic hernia more expressed. However, the sharp inflection of abdominal organs in the
patients with diaphragmatic relaxation also can associate with severe pain, which resembles
strangulation. Thereafter, a reliably differentiation of these diseases is possible only after a goal-
oriented X-ray examination.
Cancer of esophagus and cardial part of stomach. A sharp gastric shift upward with
inflection of abdominal part of esophagus can lead to dysphagia, substernal pain, disturbance of
digestion, considerable loss of weight etc. For differential diagnostics applied a contrast X-ray
examination of esophagus and stomach.
In difficult for differential diagnostics cases a pneumoperitoneum with further X-ray
examination is performed. This method allows with a major degree of reliability to establish the
diagnosis of diaphragmatic relaxation.