With a diaphragmatic hernia, abdominal organs are shifted into the chest area. What are symptoms, causes and when should an operation take place?
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In most cases, in the event of a diaphragmatic rupture (hiatal hernia), part of the stomach slides through a natural gap in the diaphragm through which the esophagus enters the abdomen. Diaphragmatic fractures are relatively common and are often coincidental findings on X-rays that do not cause any complaints.
At a glance:
What is a diaphragmatic hernia?
This leads to an expansion of the slit-shaped gap in the diaphragm through which the esophagus passes (hiatus oesophageus). This enlarged gap can cause parts of the stomach, the entire stomach or other abdominal contents to slip into the chest area.
The diaphragm (diaphragm) is a tissue plate that consists of muscles and tendons and separates the chest from the abdomen like a dome. The main artery, vena cava, esophagus, nerves and lymphatic vessels pass through the diaphragm and form three large gaps in the diaphragm. While the diaphragm firmly closes at the aortic slot and the opening for the vena cava, the muscles at the point of passage of the esophagus are comparatively loose. There is a sphincter here, which is intended to prevent the contents of the stomach from rising into the esophagus. Therefore, there is an anatomical weak point in the diaphragm, so the risk of a hernia is very high.
There are four different types of diaphragmatic hernia:
Type 1: Axial hernia (sliding hernia, sliding fracture, axial sliding hernia): With this type of diaphragmatic hernia, the stomach entrance and the upper part of the stomach move through the diaphragm into the chest area. Often the stomach parts slide back through the diaphragmatic slit to slide through again when the pressure increases.
Type 2: Paraesophageal hernia: The stomach entrance remains in the correct position below the diaphragm, the highest part of the stomach moves through the esophagus passage into the chest area.
Type 3: Mixed form: Mixtures of type 1 and type 2 can occur here. In the extreme form of this hiatal hernia, the so-called "upside-down stomach", the stomach lies completely in the chest.
Type 4: In the most severe form of a hiatal hernia, not only the stomach is affected, but other abdominal organs such as parts of the large intestine or the spleen can also enter the chest area.
There are very rarely diaphragmatic fractures in which organs of the abdominal cavity pass through other openings in the diaphragm. These are summarized under the term extriatal (outside the esophageal slit) diaphragmatic hernias.
90 to 95 percent of all diaphragmatic hernias are thought to be type 1 hiatal hernias. Diaphragmatic hernias can occur in people of all ages, but are mostly congenital or found in older people. In about two to five out of 10,000 newborns, there is a congenital diaphragmatic defect, in adults around 11,000 hiatal hernias are diagnosed annually. Men are affected about twice as often as women.
How does a diaphragmatic hernia develop?
During normal swallowing, the esophagus is shortened by several centimeters to ensure the transport of food. In combination with increased pressure in the abdominal cavity, such as occurs when coughing, sneezing, pressing or during heavy physical work, the esophagus pulls the upper part of the stomach upwards. A normal-strengthened diaphragm only allows the esophagus to pass through there.
Congenital diaphragmatic hernias usually arise due to an abnormal development of the diaphragm. In the embryonic period, a developmental disorder in the fourth to twelfth week of pregnancy can lead to a defect in the diaphragm.
Adults have usually acquired a diaphragmatic hernia in the course of life. There are various risk factors for this:
Increased age: With age, the connective tissue loses flexibility and the supporting structure is weakened. This is especially true for people who are naturally weak in connective tissue.
Increase in abdominal pressure: Increased pressure in the abdominal cavity favors the development of a diaphragmatic hernia. The reasons for this include, for example, pregnancy, severe pressure in the case of constipation, prostate problems and childbirth, as well as an excessive amount of fatty tissue in the abdomen if you are excessively overweight.
Diaphragmatic surgery: A previous operation on the diaphragm increases the risk of fracture.
Male gender: The frequency of a diaphragmatic rupture is twice as high in men as in women.
What are the symptoms of hiatal hernia?
It is assumed that hiatal hernias do not cause symptoms in nine out of ten cases and those affected do not know about their diaphragmatic hernia, especially in type 1. The diagnosis is then only made by chance, for example as a secondary finding of a gastroscopy or an X-ray examination. If there are only mild symptoms that are not noticed in everyday life, these can be felt when leaning forward, during heavy physical exertion such as lifting heavy loads and in situations that increase the pressure in the abdominal cavity.
In newborns, a large diaphragmatic rupture leads to displacement and constriction of the heart and lungs in the chest area and is therefore a life-threatening situation. Even in adults, the displacement of large parts of the abdominal organs into the chest area leads to displacement of the heart and lungs, with circulatory problems and shortness of breath.
Symptoms of type 1 hernias
Type 1 diaphragmatic fractures usually cause hardly any direct complaints, but lead to the so-called reflux disease. Acidic gastric juice flows into the esophagus and causes symptoms such as heartburn and pain behind the breastbone or in the upper abdomen.
Symptoms that can be directly attributed to the diaphragmatic hernia:
- Belching
- difficulties swallowing
- Steakhouse syndrome (large chunks of food, especially pieces of meat get stuck and clog the esophagus)
- Reluctance of leftovers
- cramping pain in the upper abdomen when the hernial sac is pinched
- Back pain from organ displacement
Symptoms of type 2 hernias
The symptoms of these hernias usually only show up when the disease has already progressed. The following stages, with increasing complaints, are passed through:
asymptomatic stage: There is a diaphragmatic hernia, but no symptoms.
uncomplicated stage: There are first symptoms such as regurgitation, difficulty swallowing, feeling of pressure in the chest (especially around the heart) after eating and a slight reflux disease.
Stage of complications: In advanced cases, type 2 diaphragmatic fractures can cause severe complications. If the part of the stomach that has been penetrated is pinched for a long time, stomach ulcers can occur. If the hernial sac also twists, the blood supply is disrupted and the contained sections of the stomach can die. This is called incarceration, and it is a life-threatening situation that is accompanied by severe pain. The tissue damage in the stomach wall can also lead to unnoticed chronic bleeding. These lead to symptoms of chronic anemia, such as poor performance, pallor and palpitations. In about a third of the cases, anemia leads to the diagnosis of the diaphragmatic hernia. Breathing gastric juice into the lungs (aspiration) can lead to lung damage and breathing problems.
How do you diagnose a diaphragmatic rupture?
Since a diaphragmatic rupture in many cases does not cause any symptoms, the diagnosis is often made accidentally. However, if there are symptoms, a detailed medical history is carried out first. The right contact person for this is the family doctor, who may refer the person concerned to an internist or surgeon for further diagnostics and therapy.
To investigate a suspicion, it is not enough to do an ultrasound. Various methods of investigation are available:
roentgen
X-ray examination with contrast medium (swallow)
Gastroscopy (esophagogastroscopy)
Measurement of esophageal pressure (esophageal manometry)
Magnetic resonance imaging (MRI) and computed tomography (CT)
Treatment of diaphragmatic hernias
If the symptoms of reflux disease are the only signs of hiatal hernia, therapy is usually limited to alleviating these symptoms. As a result, however, the diaphragmatic hernia remains unchanged. The aim of treating reflux is to prevent damage to the mucous membrane and bleeding from the esophagus, which can result from the reflux of gastric juice. In addition to acid-binding agents (antacids), acid-inhibiting drugs (so-called proton pump inhibitors) and drugs that stimulate the activity of the gastrointestinal tract (prokinetics) are used.
Good changes can also be achieved through lifestyle changes. These are:
- Weight loss
- Sleep with a raised headboard
- Avoiding large meals and meals right before bed
- Avoid alcohol, acidic foods, nicotine, chocolate, peppermint and caffeine
Diaphragmatic hernia surgery
Surgery is required to remove the diaphragmatic hernia. This is necessary for severe complaints and the risk of complications. The aim of the surgical treatment is to reduce the size of the fracture portal, to remove the hernial sac and to completely move the organs that have passed through into the abdominal cavity. The duration of illness after the operation depends on the extent of the existing diaphragmatic hernia.
During the operation of the diaphragmatic hernia (fundoplication), the stomach mouth is pulled back into the abdominal cavity and fixed under the diaphragm with a cuff made of stomach tissue. The operation can usually be performed as part of a laparoscopy.
In rare cases, surgery is also considered in the absence of symptoms to avoid possible complications. The so-called transabdominal gastropexy is most often performed. During this operation, the affected parts of the stomach are pulled back into the abdominal cavity and then sewn to the anterior abdominal wall. If the stomach is surgically fixed to the diaphragm after withdrawal, this is called fundopexy. Hiatoplasty is the surgical narrowing of the slit for the esophagus. This is done by suturing or introducing a biological network that strengthens the diaphragm.
Can you avoid a diaphragmatic rupture?
Obesity and lack of exercise are risk factors that can be eliminated. Normal weight and exercise, in particular strengthening the abdominal and core muscles, reduce the amount of internal abdominal fat and improve the support function of the muscles. Correct seating of the internal organs and the firmness of the anatomical structures prevent excessive displacement of the internal organs.
Switching your diet to multiple, smaller meals and foregoing a large meal before bed can also reduce your risk.
Course and forecast with and without surgery
How a diaphragmatic hernia develops is very different and depends on the type of hernia and the size of the hernia. The complaints can increase in the course of life. For most of those affected, the symptoms of a diaphragmatic rupture can be alleviated naturally by a lifestyle change or by medication. In 80 to 90 percent of the cases, no further treatment of the diaphragmatic hernia is necessary.
If the question of surgery is yes or no, it is good to know that in most cases the symptoms disappear completely after the operation. 90 percent of those who have undergone surgery are completely symptom-free after the operation.
A diaphragmatic rupture is rarely dangerous. With the right therapy, secondary effects can usually be avoided. Serious, life-threatening complications are very rare events.