HIATAL HERNIA TYPE OF HERNIA DIAPHRAGMATIC HERNIA

Hiatal hernia is a condition in which the upper portion of the

OVERVIEW

Congenital diaphragmatic hernia (CDH) is a congenital malformation (birth defect) of the diaphragm. The most common

stomach protrudes into the chest cavity through an opening of the diaphragm called the esophageal hiatus. This opening usually is large enough to accommodate the esophagus alone. With weakening and enlargement however, the opening (or herniation) can allow upward passage or even entrapment of the upper stomach above the diaphragm.

Hiatal hernia is a common condition. By age 60, up to 60% of people have it to some degree.

There are 2 types of hiatal hernia.

o The most common (95%), The sliding type, as its name implies, occurs when the junction between the stomach and esophagus slides up through the esophageal hiatus during moments of increased pressure in the abdominal cavity. When the pressure is relieved, the stomach falls back down with gravity to its normal position.

o The fixed type (or paraesophageal) implies that there is no sliding up and down. A portion of the stomach remains stuck in the chest cavity.

type of CDH is aBochdalek hernia; other types include Morgagni's hernia, diaphragm eventration and central tendon defects of the diaphragm. Malformation of the diaphragm allows the abdominal organs to push into the chest thereby impeding proper lung formation.CDH is a life-threatening pathology in infants, and a major cause of death due to two complications: pulmonary hypoplasia and pulmonary hypertension.[1] Experts disagree on the relative importance of these two conditions, with some focusing on hypoplasia, others on hypertension.[2] Newborns with CDH often have severe respiratory distress which can be life-threatening unless treated appropriately.

Types of congenital diaphragmatic hernia

Bochdalek hernia

The Bochdalek hernia, also known as a postero-lateral diaphragmatic hernia, is the most common manifestation of CDH, accounting for more than 95% of cases. In this instance the 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 structures during fetal development. As a result, the abdominal organs such as the stomach, small intestine, spleen, part of the liver, and the kidney appear in the chest cavity. The lung tissue on the affected side is thus not allowed to completely develop.

Congenital diaphragmatic hernia is seen in 1 out of every 2,200 to 5,000 live births. Most affect the left side. Having a parent or sibling with the condition slightly increases your risk.

CAUSESIt involves three major defects.

A failure of the diaphragm to completely close during development.

Herniation of the abdominal contents into the chest

Pulmonary hypoplasia

The symptoms include acid reflux, and pain, similar to heartburn, in the chest, and upper stomach.In most patients, hiatus hernias cause no symptoms. Sometimes patients experience heartburn and regurgitation, when stomach acid refluxes back into the esophagus.

CLINICAL MANIFESTATION

Severe breathing difficulty usually develops shortly after the baby is born, because of ineffective movement of the diaphragm and crowding of the lung tissue, which causes collapse. The reason why this occurs is not known.

Other symptoms include: Bluish colored skin due to lack of oxygen Rapid breathing (tachypnea)

Fast heart rate (tachycardia)

Exams and Tests

A complete physical exam will focus on the digestive, pulmonary (lungs), andcardiovascular (heart) systems. A rectal exam and stool test for blood may be necessary to determine if there is bleeding from the digestive tract.

Initial tests

o Electrocardiogram (ECG) to look for electrical disturbances of the heart from disease

DIAGNOSTIC EVALUATIONS This condition can often be diagnosed before birth and fetal

intervention can sometimes help, depending on the severity of the condition.[11] Infants born with diaphragmatic hernia experience respiratory failure due to both pulmonary hypertension and pulmonary hypoplasia. The first condition is a restriction of blood flow through the lungs thought to be caused by defects in the lung. Pulmonary hypoplasia or decreased lung volume is directly related to the abdominal organs presence in the chest cavity which causes the lungs to be severely undersized, especially on the side of the

o Chest x-ray to look for pneumonia, collapsed lung, or other problems in the chest

o Blood tests to look for anemia, infection, or injury to the heart, pancreas, or liver

o Other tests focusing on the cardiovascular and pulmonary organ systems if suspicion remains high for problems in these areas

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).

hernia.

Survival rates for infants with this condition vary, but have generally been increasing through advances in neonatal medicine. Work has been done to correlate survival rates to ultrasound measurements of the lung volume as compared to the baby's head circumference. This figure known as the lung to head ratio (LHR).

Medical treatment for hiatal hernia may include prescription-strength antacids such as lansoprazole (Prevacid), omeprazole(Prilosec), or rabeprazole (Aciphex).

Surgical treatments rarely are necessary or worth the risk unless an emergency exists, such as a strangulated hiatal hernia.

o Endoscopy may be performed by a gastroenterologist. A long fiberoptic scope is passed through the mouth and into the stomach looking for an ulcer, tumor, or other tissue damage. Sometimes a biopsy is needed.

THERAPEUTIC MANAGEMENT

A diaphragmatic hernia is an emergency that requires surgery. Surgery is done to place the abdominal organs into the proper position and repair the opening in the diaphragm.

The infant will need breathing support until he or she recovers from surgery. Some infants are placed on a heart/lung bypass machine, which gives the lungs a chance to recover and expand after surgery.

If a diaphragmatic hernia is diagnosed during pregnancy (around 24 to 28 weeks), fetal surgery may be considered.

- same nursing management.- NURSING MANAGEMENT

1. Assessment if the infant at birth is an integral component of 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.