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DIAPHRAGM AND
HIATUS HERNIA
Anatomy of
diaphragm
 Diaphragm
 Diaphragmatic
communications
Physiology
Normal anatomy of LES
Normal anatomy
of LES
Normal anatomy of LES
Hernia-peritoneum diverticulum
Clasification
 Congenital
 Accuired
Congenital 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 posterolateral 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 shunt
Viscera herniation (stomach, intestines, liver*, kidneys, spleen and gall
bladder)
Abnormal position of certain viscera inside the abdomen
Stomach visualization out of its usual position
Intrauterine growth retardation*
Polyhydramnios*
Fetal hydrops*
* bad prognosis
Fetal diafragmatic hernia:
Ultrasound diagnosis
Prenatal MR Imaging - single-shot turbo spinecho (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 repair
 Liquid ventilation
 Pulmonary transplantation
 Pharmacology
– Prostacyclin derivatives
– Calcium channel blockers
– Phosphodiesterase inhibitors
Prognosis
 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.
ADULT
DIAPHRAGMATIC
HERNIA
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 nonemergency
 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 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 intraabdominal 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