DIAPHRAGM AND DIAPHRAGM AND HIATUS HERNIAHIATUS HERNIA

Anatomy of diaphragm

Diaphragm Diaphragmatic

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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