DIAPHRAGM AND HIATUS HERNIA

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DIAPHRAGM AND HIATUS HERNIA
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Anatomy of diaphragm

• Diaphragm
• Diaphragmatic communications

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Physiology
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Normal anatomy of LES
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Normal anatomy of LES
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Normal anatomy of LES
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Hernia-peritoneum diverticulum
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Clasification

• Congenital
• Accuired

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Congenital hernia
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Congenital diaphragmatic hernia
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Incidence

• 1 2000-5000 live birth
• 8 of all major congenital anomalies
• mortality rate nearing 70 percent
• CDH accounts gt 1 of total infant mortality in
  USA
• Cost per new case CDH 250 000

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Diaphragm Development
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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

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Congenital Diaphragmatic Hernias (CDH)

• Types of Congenital Diaphragmatic Hernias (CDH)
• Bochdalek
• Morgagni
• Diaphragmatic eventration
• Central tendon defects

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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

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Morgagni Hernia

• anterior defect of the diaphragm
• referred to as Morgagnis, 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

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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

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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

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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
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Fetal diafragmatic hernia Ultrasound diagnosis
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Prenatal MR Imaging - single-shot turbo spin-echo
(HASTE)- of congenital diaphragmatic hernia
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Prenatal MR Imaging of congenital diaphragmatic
hernia
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Pulmonary hypoplasia
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Anatomopathology show of CDH
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Prenatal Counseling multidisciplinary team

• patient's obstetrician
• perinatologist
• geneticist
• surgeon
• social worker

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Prenatal management

• Glucocorticoids
• Thyrotropin-releasing hormone
• Fetal surgical therapy (Antenatal surgical
  intervention, In utero tracheal occlusion )

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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

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Postnanal Diagnosis

• Respiratory distress
• Scaphoid abdomen
• Auscultation of the lungs reveals poor air entry
• Shift of the heart to the side opposite

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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).

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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

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Postnatal management

• Mechanical ventilation
• Nitric Oxide
• Surfactant
• Surgery

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Operative approach
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The defect in the diaphragm

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Patch repair of a large defect
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Evolving Therapies

• In utero repair
• Liquid ventilation
• Pulmonary transplantation
• Pharmacology
• Prostacyclin derivatives
• Calcium channel blockers
• Phosphodiesterase inhibitors

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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.

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ADULT DIAPHRAGMATIC HERNIA
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Classification

• ?Asymptomatic congenital diaphragmatic hernia
• Posttraumatic or postoperative
• Hiatus hernia

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Posttraumatic hernia
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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

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Diagnostic

• Plain thoracic X-Ray
• Nasogastric tube X-ray
• Barium or Gastrographin studies if non-emergency
• CT-scan

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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

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HIATAL HERNIA
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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)

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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

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Paraesophageal Hiatal Hernia

• The fundus and possibly portions of the stomachs
  greater curvature, rolls through the esophageal
  hiatus and into the thorax beside the esophagus

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A Comparison of the normal stomach, sliding
hiatal hernia and rolling hiatal hernia
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Diagnostic Tools

• Barium Swallow
• CXR
• Endoscopy with biopsy
• Stool for quiac
• Esophageal manometry

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Diagnostic Tools
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Key Features of Hernias

• Paraesophageal hernia
• Feeling of fullness and breathlessness after
  eating
• Feeling of suffocation
• Cheat pain that mimics angina
• Symptoms worse in recumbent position

• Sliding hiatal hernia
• Heartburn
• Regurgitation
• Chest pain
• Dysphagia
• Belching

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Symptoms
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Complications

• Slow bleed
• Anemia
• Pulmonary Aspiration

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Risk Factors

• Increased intra-abdominal pressure
• Obesity
• Pregnancy
• Bending
• Coughing
• Weight lifting
• Age

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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

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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

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Postoperative Care

• Risk for bleeding, infection and organ injury
• Respiratory Care
• NG tube Management
• Nutritional Care

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Results

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Complications

• Temporary dysphagia
• Gas bloat syndrome (avoid carbonated beverages)
• Atelectasis, pneumonia
• Obstructed NG tub
• Reccurrent GERDe
• RARE
• Mediastinitis
• Fistula

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Complications