2024 - Diaphragmatic hernia (hiatal hernia) • causes, symptoms & treatment

With a diaphragmatic hernia, abdominal organs are shifted into the chest area. What are symptoms, causes and when should an operation take place?

: In the case of a diaphragmatic hernia, the stomach enters the chest cavity upwards, although the diaphragm, which is stretched like a parachute, actually separates the abdominal organs from the chest cavity.; © iStock.com/magicmine

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.

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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.