Overview of the disease
Abdominal organs through the congenital defect of the diaphragm or acquired fissure protrudes into the thoracic cavity of the disease manifested as epigastric discomfort, pain, belching, or abdominal distension, vomiting and other intestinal obstruction phenomenon can be caused by the congenital absence of the diaphragm. Trauma and increased abdominal pressure can also cause the onset of diaphragmatic hernia in infants and traumatic diaphragmatic hernia requires surgical treatment, while hiatal hernia in adults can be treated conservatively if there are no obvious symptoms.
Definition of diaphragmatic hernia
Diaphragmatic hernia is a condition in which an intra-abdominal organ enters the thoracic cavity through a weak hole, defect or traumatic fissure in the diaphragm.
Common diaphragmatic hernias include esophageal hiatal hernia, thoracoabdominal hiatal hernia, parasternal diaphragmatic hernia, traumatic diaphragmatic hernia, etc. The following is an introduction to these types of diaphragmatic hernias.
Classification
Classification according to the presence or absence of trauma
Traumatic diaphragmatic hernia: caused by trauma.
Non-traumatic diaphragmatic hernia: including congenital and acquired.
Congenital: common thoracoabdominal hiatal hernia, parasternal hiatal hernia, etc., also includes congenital esophageal hiatal hernia.
Acquired: mainly includes acquired esophageal hiatal hernia.
Morbidity
Mostly occurs over 40 years old, more women than men, especially obese menstruating women.
The incidence of hiatal hernia of the esophagus is 0.52% or 52 per 10,000 people [1].
The incidence of pediatric congenital diaphragmatic hernia is about 1:3000, i.e., 1 in 3,000 children, making it one of the more common pediatric congenital disorders [2].
Etiology
Causes of the disease
Under the action of congenital or acquired factors, the diaphragm has defects or enlarged fissures, and the pressure in the abdominal cavity increases, and the internal organs or tissues in the abdominal cavity (such as the stomach, intestines, and the greater omentum) can enter the thoracic cavity through the weak area of the diaphragm, which then leads to the formation of diaphragmatic hernia. The specific etiologic factors are listed below:
Anatomical factors
The diaphragm is an important respiratory muscle located between the abdominal and thoracic cavities, and there are three fissures present, namely the esophageal fissure, the aortic fissure, and the vena cava fissure [3-4].
These three clefts are relatively weak areas of the body. If the hiatus enlarges or the pressure in the abdominal cavity increases, organs and tissues in the abdominal cavity can be allowed to pass through these hiatuses into the thoracic cavity, leading to the formation of diaphragmatic hernia.
Pathologic Factors
Trauma.
Thoracic and abdominal surgeries and traumatic injuries, such as vehicle impacts, stab wounds, gunshot wounds, earthquake injuries, fall injuries, etc., may injure the diaphragm, leading to rupture of the diaphragm, allowing abdominal contents to enter the thoracic cavity, causing a traumatic diaphragmatic hernia.
Congenital developmental abnormalities
Unilateral or bilateral developmental defects of the diaphragm during embryonic period may lead to the entry of abdominal contents into the thoracic cavity through the diaphragmatic defect, causing congenital diaphragmatic hernia [1].
Natural atrophy of the diaphragm
With age, the diaphragm muscle relaxes and atrophies, resulting in the enlargement of the fissure, which allows the abdominal contents to enter the thoracic cavity and form a diaphragmatic hernia.
Increased pressure in the abdominal cavity
Factors such as obesity, constipation, chronic coughing and difficulty in urination may lead to increased pressure in the abdominal cavity.
When the pressure in the abdominal cavity increases, if the diaphragm has a weak area at the same time, it is prone to diaphragmatic hernia [5].
High risk factors
Adverse factors during the embryonic period: the mother’s frequent exposure to secondhand smoke, alcohol consumption, and internal or external use of retinoids during pregnancy may induce abnormal development of the diaphragm in the embryo, which may lead to the formation of diaphragmatic hernia [6].
Adverse dietary factors: such as overeating, preference for fatty foods, etc. are likely to cause obesity, and obese people are prone to increased abdominal pressure, which may lead to rupture of the diaphragm, and then prone to diaphragmatic hernia.
Thoracic and abdominal trauma: car accidents, stabbing, gunshot and other accidents suffered by the crowd, if the injury to the thoracic and abdominal areas, easy to damage the diaphragm, resulting in rupture of the diaphragm, the formation of diaphragmatic hernia.
Congenital abnormalities of diaphragm development: If the diaphragm develops abnormally during the embryonic period, the abdominal organs can enter the chest cavity through the defect, causing diaphragmatic hernia.
Older people, the older they are, the higher the degree of relaxation and atrophy of the diaphragm, which makes them prone to diaphragmatic hernia.
Obesity: a large accumulation of abdominal fat in such people can cause excessive pressure in the abdominal cavity, which, if maintained for a long time, may cause rupture of the diaphragm and diaphragmatic hernia.
Difficulty in urination, constipation: due to constipation, often need to squat for a long time, make a larger force to defecate and urinate, which can lead to increased pressure in the abdominal cavity, prone to diaphragmatic hernia.
Symptoms
Main Symptoms
Different types of diaphragmatic hernia, the clinical manifestations are generally different, the following describes the common types of diaphragmatic hernia [6-7].
Thoracoabdominal hiatal hernia
Clinical manifestations are related to the size of the diaphragmatic hiatus.
If the hiatus is small, it may be asymptomatic, but the narrow hernia hole may also cause strangulation or necrosis of the herniated gastrointestinal tract.
If the defect is large, a large number of abdominal organs such as stomach, intestines, greater omentum, spleen, liver, kidney, etc. can herniate into the thoracic cavity, resulting in displacement of the lungs and the heart under pressure.
Patients may have nausea, vomiting, abdominal pain, chest tightness, shortness of breath, tachycardia, cyanosis and other symptoms, and in severe cases, respiratory and circulatory failure may occur.
Parasternal diaphragmatic hernia
Patients are mostly asymptomatic.
Some may have gastrointestinal symptoms such as vague pain in the epigastrium and fullness after meals.
Occasionally there are spasmodic abdominal pain, vomiting and other symptoms of intestinal obstruction.
It may be accompanied by cough and dyspnea.
Respiratory symptoms are more common in infants. In children, gastrointestinal symptoms are more common.
Esophageal hiatal hernia
Hiatal hernia can often be associated with discomfort or burning pain in the upper abdomen, belching, bloating, and acid reflux.
Acid reflux can cause esophagitis or ulcers with nausea, retrosternal pain, difficulty swallowing, and vomiting blood.
Traumatic diaphragmatic hernia
Usually occurs immediately after trauma, a few can be detected months or even years after the injury.
It may be accompanied by splenic rupture producing intra-abdominal blood accumulation.
There may also be obvious dyspnea, chest and abdominal pain, and radiating pain to the shoulder.
Complications
Esophageal stenosis
Esophageal stenosis occurs in a small number of patients with symptoms of gastroesophageal reflux.
It manifests as painful swallowing, dysphagia, and vomiting after eating.
Aspiration pneumonia
If the symptoms of acid reflux are severe, leading to accidental aspiration of stomach acid into the lungs, it may further lead to aspiration pneumonia.
It manifests as symptoms such as cough, shortness of breath, fever, etc. In severe cases, dyspnea or even respiratory failure may occur [8].
Hernia sac incarceration
If the hernia sac is large, incarceration may occur.
It manifests as sudden onset of severe epigastric pain, blood in stool, vomiting blood, and complete inability to swallow.
Anemia
In case of recurrent gastrointestinal bleeding, or chronic leakage of blood from the diaphragmatic hernia, it may lead to the development of anemia.
It manifests as pallor, pale conjunctiva, dizziness, and easy fatigue.
Consultation
Department of Medicine
General Surgery
When patients have symptoms such as vague pain in the upper abdomen, fullness after meals, acid reflux, nausea and belching, they need to consult the general surgery department promptly.
Pediatrics
When a child develops the above symptoms, he/she can go to the Department of Pediatrics.
Emergency Medicine
When the patient has sudden onset of symptoms such as dyspnea, chest pain and vomiting, he/she should directly call 120 or immediately consult the Emergency Department.
Preparation
How to get to the doctor: registration, preparation of documents, common problems
Tips
Try to keep a record of the duration of symptoms such as epigastric pain, acid reflux, vomiting, etc., so that you can give your doctor more information.
Try to have a family member accompanying the patient to avoid accidents.
Preparation Checklist
Symptom list
Particular attention should be paid to the time of onset of symptoms, special manifestations, etc.
Are there any symptoms such as abdominal pain, bloating or fullness after meals, nausea and vomiting, acid reflux, belching, etc.?
Are there any symptoms such as cough, chest tightness, shortness of breath, dyspnea, etc.?
Is there tachycardia, cyanosis?
Is there nausea, retrosternal pain, difficulty swallowing, or even vomiting of blood? When did it occur and how much bleeding was there?
When did these discomforts begin? Any aggravating or relieving factors?
Medical History Checklist
Is there a history of thoracic and abdominal surgery and trauma?
Any congenital defects in diaphragm development?
Is there any overweight condition?
Is there any dysuria, chronic constipation, chronic cough?
Have any tests been done since the onset of symptoms?
Checklist
Examination results in the last six months, which can be brought to the doctor’s office.
Imaging tests: chest and abdominal X-ray plain film, abdominal ultrasound, barium enema examination, chest and abdominal CT.
Endoscopy: Gastroscopy.
Other tests: Esophageal function test.
Medication List
Medications used in the last 3 months, if available in boxes or packages, carry with you to the doctor’s office
Gastric stimulants: Domperidone, etc.
Acid suppressants: Omeprazole, Lansoprazole, etc.
Diagnosis
Diagnosis is based on
Medical history
History of trauma such as thoracic and abdominal surgery and trauma.
There is a congenital developmental defect of the diaphragm.
Elderly with atrophy of the diaphragm and other muscles.
Obese or overweight.
Suffering from urinary difficulties, chronic constipation and chronic cough [9].
Clinical manifestations
There are symptoms such as abdominal pain, bloating or fullness after meals, nausea and vomiting, acid reflux and belching.
There are symptoms such as cough, chest tightness, shortness of breath, and dyspnea.
There is tachycardia, cyanosis.
There is nausea, retrosternal pain, dysphagia, and even vomiting of blood [10].
Imaging.
Chest and abdominal radiographs
is the diagnostic method of choice for diaphragmatic hernia.
If the esophageal segment under the diaphragm is shortened, widened or disappeared, the cardia is pulled upward in the shape of a curtain, and the gastric sac is seen on the diaphragm, it suggests the occurrence of diaphragmatic hernia.
If the X-ray results are normal, the possibility of diaphragmatic hernia cannot be ruled out, and other examinations such as abdominal CT and abdominal ultrasound should be performed for confirmation.
Chest and abdominal CT
It can clearly show the abnormalities of thoracic organs and abdominal organs.
It is suitable for diagnosis of patients suspected to be accompanied by upper gastrointestinal obstruction with high sensitivity.
If abdominal organs and tissues such as stomach, esophagus and intestines are found in the thoracic cavity, and the intestines are inflated and dilated with thickening of the intestinal wall, it suggests the occurrence of diaphragmatic hernia with intestinal obstruction.
It can assist the doctor in choosing a surgical plan.
Abdominal ultrasound
It is a safe and easy examination.
It can be used to detect dilatation and peristalsis of the intestines in the chest cavity with fluid echogenicity and gas dotted echogenicity, suggesting the development of a diaphragmatic hernia.
It can also be used to measure the length of the abdominal esophagus in order to determine the extent of diaphragmatic hernia [10].
Barium enema
A barium enema provides a clearer visualization of the elevated stomach or colon in relation to the diaphragm, leading to a definitive diagnosis.
Esophageal function test
It is an important auxiliary examination modality for hiatal hernia of the esophagus, including both esophageal kinetic function examination and 24-hour pH and impedance pH monitoring of the lower esophagus, i.e., manometry and acidometry.
It can be used to understand the length of the high pressure area of the esophagus, intragastric pressure, the degree of gastroesophageal reflux, etc., which is an important reference value for the selection of the subsequent surgical approach.
Differential Diagnosis
Angina pectoris
Similarities: both have chest pain radiating to the shoulder.
Differences
Angina pectoris is often located in the middle retrosternum, often occurs after physical activity, and rarely has a burning sensation. Contained nitroglycerin relieves symptoms.
Continuous ambulatory electrocardiographic observation and cardiac enzyme testing can help in the differential diagnosis.
Peptic ulcer
Similarities: Both have relatively similar GI symptoms. Both can have belching and abdominal pain.
Differences.
Acid-suppressive therapy is effective in peptic ulcers, and symptoms such as epigastric discomfort, acid reflux, and heartburn usually occur on an empty stomach, independent of changes in body position.
Endoscopy can clarify the diagnosis.
Gastric perforation
Similarities: The symptoms of gastric perforation are relatively similar to those of diaphragmatic hernia in the advanced stage of incarceration.
Differences
Generally speaking, gastric perforation presents with persistent cutting pain in the epigastrium.
Free gas under the diaphragm can be seen on standing abdominal radiographs and can be clearly identified.
Left pneumothorax
Similarity: Left pneumothorax is similar to diaphragmatic hernia in terms of pain.
Differences
However, left-sided pneumothorax has a rightward shift of the heart, far weaker heart sounds, a drumming sound on percussion in the left upper chest, a turbid sound on percussion in the lower chest, a weakened palpitation, and weakened breath sounds.
Chest X-ray radiographs of the left thoracic cavity have a gas-liquid flat sign, which can be clearly identified by this examination [8].
Treatment
The purpose of treatment: to control and alleviate symptoms such as reflux, correct anatomical defects, strengthen the diaphragm, and prevent the emergence of complications.
Treatment principles
The treatment of diaphragmatic hernia includes both non-surgical and surgical treatment.
In general, hiatal hernia in adults tends to be less symptomatic, without symptoms of digestive obstruction, and can be treated non-surgically.
All other types of diaphragmatic hernia require surgical repair [9].
Non-surgical treatment
In patients with diaphragmatic hernia, most of the symptoms are mild and dominated by symptoms such as acid reflux, which can be controlled and relieved by conservative medical treatment. However, these patients have a high rate of recurrence after discontinuation of medication, and many require lifelong treatment.
Acid-suppressing drugs
Most reflux symptoms can be reduced or controlled by acid-suppressing drugs. Commonly used drugs are PPIs (proton pump inhibitors) such as omeprazole, lansoprazole, and esomeprazole [10].
H2 receptor blockers such as ranitidine, famotidine and other esophageal and gastric dynamics are also available for milder symptoms.
Gastrointestinal stimulants
In some patients, esophageal function tests reveal decreased esophagogastric emptying ability, in which case domperidone or mosapride can be added to relieve symptoms.
Surgery
Purpose of treatment
Reach the diaphragm therapeutic point through surgical method, which serves to strengthen the diaphragm.
Surgical methods
Generally speaking, surgery can be categorized into traditional open surgery and minimally invasive thoracoscopic or laparoscopic surgery.
Indications for surgery
Congenital diaphragmatic hernia in infants and young children: especially thoracoabdominal hiatal hernia, often combined with pulmonary dysplasia, the younger the age, the more serious the condition. It should be operated as early as possible.
Traumatic diaphragmatic hernia: in principle, early detection, early diagnosis, early surgical treatment.
Adult diaphragmatic hernia with more serious symptoms.
Contraindications to surgery
Severe respiratory distress, decreased oxygen saturation, inability to tolerate general anesthesia.
Children with severe cardiopulmonary congenital diseases and malnutrition.
Patients with symptoms that are not obvious after conservative medical treatment.
Postoperative care
After the operation, you need to lie flat on the pillow for 6 hours, with the head tilted to one side, which can effectively prevent the occurrence of aspiration.
Pay attention to whether the chest drainage tube, abdominal drainage tube and gastric tube are fixed, if loose, inform the medical staff in time to deal with it.
Cough and sputum more often after the operation. If the patient is inconvenient, family members should assist in turning over and patting the back to help expel sputum.
Recovery requires semi-recumbent position as well as high slope position, which is favorable for breathing, and at the same time can reduce the tension of abdominal incision and reduce pain.
Questions you may be concerned about
Is diaphragmatic hernia a major surgery?
Diaphragmatic hernia is major surgery, but it is safe. Commonly used surgical procedures include trans-thoracic approach surgery, trans-thoracoscopic surgery, and trans-abdominal approach surgery.
A diaphragmatic hernia is a type of internal hernia and is associated with a traumatic fissure proceeding to the thoracic cavity. Usually, because the human diaphragm is above the pleural cavity and below the abdominal cavity, if you want to perform surgery locally, you need to pass through the pleural cavity or the abdominal cavity, so it is considered that diaphragmatic hernia is a major surgery. However, since the technology of diaphragmatic hernia surgery is more mature, it is safer and patients do not need to worry too much.
The common clinical diaphragmatic hernia surgery methods include trans-thoracic approach surgery, trans-thoracoscopic surgery and trans-abdominal approach surgery, etc., which are mainly applicable to the patients who have been clearly identified as purely traumatic diaphragmatic hernia, as well as patients who have failed to undergo internal medicine treatment.
Most patients with diaphragmatic hernia can be cured with standardized treatment. Patients need to strengthen the daily life management, improve the bad habits, adjust the diet structure. Secondly, patients need to go to the hospital on time for review after surgery, so that doctors can understand the condition.
How to treat diaphragmatic hernia
The treatment of diaphragmatic hernia depends on the specific condition, the most suitable treatment is the best, including surgical treatment and drug treatment, the use of drugs in accordance with medical advice.
1. Surgery: If the diaphragmatic hernia is traumatic, the abdominal organs into the chest cavity, compression of the heart and lungs, so that the mediastinum is displaced, often manifested in dyspnea, cyanosis, accelerated heart rate, circulatory failure, etc., the need for emergency surgery, the return of organs, sewing the diaphragm, in order to remove the foci of the disease, to promote the rapid recovery of the patient.
2. Drug therapy: for patients with mild symptoms of diaphragmatic hernia, most of the acid-suppressing drugs can reduce or control reflux symptoms, commonly used drugs for proton pump inhibitors, such as omeprazole. H2 receptor blockers, such as ranitidine, can also be chosen. Some patients have decreased esophagogastric emptying ability, can add domperidone and so on to relieve the symptoms.
Patients with diaphragmatic hernia are advised to go to regular hospitals in time, and listen to the advice of specialized doctors for specific treatment plans.
Prognosis
Cure
Diaphragmatic hernia cannot be cured by itself.
Most of them can be cured through regular treatment and usually have a good prognosis.
Diaphragmatic hernia may recur, especially hiatal hernia of the esophagus, which has a high recurrence rate.
Hazards
Impaired respiratory function: the diaphragm is a very important respiratory muscle, if there is a congenital defect or dysplasia, the respiratory function of the human body will be abnormal accordingly, leading to respiratory difficulties, or chest tightness, and may even lead to respiratory failure [11].
Abnormal digestive function: in people with diaphragmatic hernia, the barrier force between the abdominal cavity and the thoracic cavity will be weakened, leading to part of the stomach and intestines to enter the thoracic cavity, which in turn will cause abnormal digestive function, constipation, dyspepsia and other situations.
In severe cases, complications such as esophageal stenosis, aspiration pneumonia, hernia sac incarceration and anemia can also occur, seriously affecting daily life and even endangering life.
Daily
Daily Management
Dietary management
Care should be taken to avoid overeating, overly greasy food, spicy and stimulating food, and food that is not easy to digest, such as hot pot, fried food and drinking alcohol.
Avoid sleeping within 3 hours after eating and move around more after eating.
After the operation, you can drink water after venting, and if there is no abnormality, you can eat fluids, and gradually return to normal diet.
It is recommended to eat high protein, high vitamin, and easy to digest food, such as fish, lean meat and so on.
Life management
Avoid prolonged squatting and straining to defecate.
Avoid straining and take rest.
Maintain optimism and avoid excessive mood swings.
Get out of bed as soon as possible after the operation and gradually increase the amount of activity.
Disease monitoring
Pay close attention to the changes of body temperature and pulse rate.
Pay attention to whether there is recurrent pain, acid reflux, belching, etc. in the epigastric region.
Pay attention to observe the changes of your own condition, if there are symptoms such as fever, chest pain, dyspnea, etc., you should consult a doctor promptly.
Follow-up examination
During the recovery period, regular follow-up examinations should be conducted so that the doctor can assess the changes in the patient’s condition and adjust the dosage of medication.
The timing of the review should be determined by the specialist according to the patient’s specific condition.
If there is redness, swelling, heat or pain at the incision site, we cannot rule out the possibility of incision infection, and need to consult a doctor promptly.
Because of the diaphragmatic hernia repair, there may be difficulty in eating, and it is recommended to follow-up in the first month after surgery for upper gastrointestinal imaging. If there is no abnormal stenosis, most patients can be relieved on their own.
Patients who still have difficulty eating six months after surgery are recommended to have a follow-up examination, and very few patients need dilatation treatment or even reoperation.
Prevention
Avoid smoking and drinking during pregnancy, and avoid medications that affect the fetus to reduce the risk of congenital diaphragmatic hernia.
Avoid chest and abdominal injuries.
Patients with difficulty in urination, constipation and prolonged cough should be treated for the primary disease.
Child patients with symptoms of indigestion are advised to seek prompt medical attention.
If epigastric pain, vomiting, acid reflux and other symptoms, you need to consult a doctor in time.
Obese people need to lose weight.
Constipated people need to avoid straining to defecate, and medication can be used to assist in laxation.
Drink more water and eat more vegetables and fruits to prevent constipation.