Hernia of the esophageal opening of the diaphragm

Hernia of the esophageal orifice of the diaphragm or hiatal is listed in the International Classification of Diseases under the code K44.9.In the medical literature, the disease is often referred to as "GPOD".

The essence of pathology is the movement through the ring in the dome of the diaphragm of the underlying organs( stomach, omentum, subdiaphragmal segment of the esophagus, intestinal loops) without the obligatory accompanying peritoneal sheet.

Although diagnostic methods allow to confirm the disease with full certainty, in practice cases of prolonged treatment and observations of patients with various diseases of the stomach and esophagus caused by secondary changes are not uncommon.

Prevalence of

Among all types of hernia diaphragm on the esophagus accounts for almost 90%.The older the age, the greater the risk of the disease and the frequency of detection. In people under 50, they occur in 8% of cases, and in older age - in 70%.It is estimated that diaphragmatic hernia has up to 6% of the total adult population.

It is established that more often pathology develops in women. In early childhood, the formation of a hernia of the esophageal aperture of the diaphragm is usually associated with a congenital malformation( short esophagus) with simultaneous weakness of the muscular and connective tissue of the diaphragm. The disease is considered one of the root causes of gastroesophageal reflux in children.

Classification of

There are more than 50 classifications of hernias localized in the diaphragm. In practice, the most acceptable are those that take into account anatomical changes, the features of the formed hernia, the size of the hernia opening and the role of the subdiaphragmatic esophagus.

The most popular division of hernias by mobility is by sliding( axial, axial) and fixed near-esophagus( paraseophageal).In addition, there are mixed hiatal hernias, with a complicated course.

The share of parasophageal hernia accounts for no more than 5%( in childhood, 0.3), non-fixed in the structure occupy almost 95%( in children 99.4).

Slip hernias have the ability to fix, most often against the background of a shortening of the esophagus. Their main sign is the free movement of the upper part of the stomach and the sub-diaphragmatic part of the esophagus into the chest cavity and back. Are able to self-correct with the vertical position of a person.

Types of axial hernias are distinguished depending on the proportion of the stomach that passes into the chest cavity:

• cardiac - a small patch of cardia leaves the esophagus;
• cardiofundal - hernia consists of the cardiac and gastric body;
• subtotal - the stomach moves to the thoracic cavity before the pylorus;
• total - in the hernia is the whole body with the pyloric department.

Usually, with a fixed cardiac section, the bottom of the stomach or the entire organ, the intestinal loop, the omentum, and rarely the part of the spleen enter the stretched esophagus. This species can be impaired. Among fixed hernias, depending on the content, the following types are considered:

• foundation - the body of the stomach moves to the chest cavity;
• antral - the part of the antrum is shifted;
• intestinal - the loop of the small or large intestine passes;
• gastrointestinal - simultaneously moves the intestine and part of the stomach;
• stuffing box - in the hernia there is an epiploon.

There is a division according to the degree of enlargement( size) of the hernial opening:

• 1 degree - in the supra-diaphragm space lies only the abdominal segment of the esophageal tube, the stomach is pulled up to the diaphragm;
• 2 degree - the antechamber and the cardial part pass upwards, gastric folds appear in the diaphragmatic opening;
• 3 degree - in addition to the abdominal part of the esophagus, the body and the antral part of the stomach pass into the chest cavity.

Why does a hernia form?

The causes of the hiatal hernia consist of two mechanisms. Change in the structure of the musculoskeletal apparatus of the diaphragm, loss of elasticity, atrophy with pronounced loss of tone and tension.

This process is typical for senile age, people who move little, do not exercise, have lost weight for various reasons, patients with chronic systemic diseases of connective tissue, blood circulation, metabolic disorders( Marfan syndrome, hemorrhoids, diverticulosis in the intestine, flat feet, diabetes), if the children of the basis of violations - genetic diseases or underdevelopment of muscle groups due to a complicated pregnancy of the mother, anomalies( achalasia, short esophagus).

Another important factor is the increase in intra-abdominal pressure. It grows in people:

• with chronic diseases accompanied by flatulence and constipation;
• with prolonged indomitable vomiting;
• with ascites( an enlarged abdomen caused by the penetration of plasma from the vessels into the abdominal cavity with congestion) with cardiac decompensation, liver cirrhosis;
• with a large benign or malignant tumor located in the peritoneal cavity;
• who suffered a stomach injury;
• engaged in weightlifting;
• with lifting physical exertion;
• with abdominal obesity;
• suffering from chronic diseases of the lungs, bronchi, larynx with a strong cough.

Physiological pregnancy usually does not lead to a hernia, but if a woman is weakened by one of the listed diseases, then even a normal uterine enlargement affects heavily the muscle tone and presses downwards onto the diaphragm. In the case of multiple pregnancies or complicated delivery, the prognosis process worsens.

Disturbed peristalsis of the esophagus, causing excessive tension and pulling up the cardiac part of the stomach, accompany inflammatory diseases of the esophagus, reflex mechanism supports peptic ulcer, calculous cholecystitis and pancreatitis, chronic gastroduodenitis in 15-20% of patients( spasm of longitudinal muscles occurs).

Symptoms and their origin

The disease develops gradually, characterized by a chronic course. At half of patients at an early stage any characteristic symptoms of hiatal hernia are absent, they try to treat gastritis, biliary dyskinesia, pancreatitis.

The components of the hernia rise above the area of ​​the esophageal-gastric junction

These diseases can not be classified as "masks" of the diaphragmatic hernia, because the zone of the gastroesophageal junction is equipped with powerful innervation, participates in the regulation of digestion processes, especially in creating the necessary muscle tone. With the slow movement of the sub-diaphragm segment of the esophagus and stomach upward, a greater curvature, a bottom, is first drawn into the hernial opening.

The small curvature assumes a horizontal position. This localization creates the conditions for the occurrence of reflux( reverse) casting of the contents, as it changes the angle of the connection and eliminates the fold-valve, which acts as a hermetically closed lumen. The mechanism of pathology explains the constant heartburn in patients, frequent eructations.

Slipping a part of the organs upside down with an unfixed hernia produces a constant irritation of the reflex zone, therefore, despite the rare infringement and asymptomicity, the indication for surgical treatment is the transition to the chest cavity up to 70% of the stomach volume.

The fixed hernia of the esophageal part of the diaphragm is distinguished by the duration and persistence of the symptoms. This is a rare but dangerous pathology. Significantly leads to complications that require surgical intervention for emergency indications.

The most common manifestations are:

• pain - the intensity can be different, localized in the epigastric region, irradiate into the left shoulder blade, the shoulder, behind the sternum, sometimes have a shingling character, cramping or dull pain in the right hypochondrium confirm the involvement of the motor activity of the bile ducts, painfulthe syndrome is related to the position of the body( it is strengthened by lying, with leans forward);
• heartburn - accompanies pain, does not last long after overeating;
• belching eaten recently food, air - caused by the reverse casting of the food lump from the stomach into the esophagus due to the defeat of the lower sphincter, accompanied by a temporary relief of the condition;
• difficulty in swallowing - occur in 1/3 of patients with narrowing of the esophagus in the lower segment, especially when eating hot or cold dishes( in children it is rare).

Belching affects 60% of

Less often patients are concerned about:

• a long agonizing hiccup;
• nausea, vomiting( sometimes with blood);
• feeling bitterness in the mouth;
• hoarse voice;
• burning on the root of the tongue;
• increased salivation;
• a tendency to lower blood pressure.

These symptoms are caused by irritation of the branches of the vagus nerve, ingestion of acidic contents and bile in the larynx( especially in sleep).The manifestations of sliding hernia are characterized by heartburn, as more conditions are created for the formation of gastro-esophageal reflux. Fixed hernia gives pain, especially if it reaches large sizes.

When compressing the pleural cavity, dyspnoea, arrhythmias( extrasystole, paroxysmal tachycardia) associated with food intake may occur. A serious diagnostic error occurs when the symptoms are confused with heart disease. Hernias of the esophageal orifice can be taken for angina pectoris, with no effect to treat arrhythmias. Patients often fall ill with pain in the cardiology department. What complications does the hiatal hernia cause?

The heavier the course of the hernia, and the longer the targeted treatment is delayed, the more the risk of complications increases. Most often observed:

• infringement of the muscles of the diaphragm of organs displaced from their anatomical site;
• reflux esophagitis - inflammation of the esophagus, as a result of the constant casting of acidic contents of gastric juice, leads to ulcers on the surface of the mucosa, perforation;
• formation of adhesions, scars, esophageal lumen narrowing;
• stomach ulcer;
• acute or chronic bleeding from varicose vessels of the esophagus and stomach, anemia;
• angina attacks with which it is difficult to fight nitro drugs;
• Barrett's esophagus is a precancerous disease.

The probability of malignant degeneration of mucosal cells increases

How are the signs associated with the severity of the disease?

The ventral part of the esophagus is covered with a parietal leaflet of the peritoneum from the front and sides, and the stomach lies completely inside the bed of the visceral peritoneum. If the posterior wall of the esophagus is drawn into the diaphragmatic opening, then the classic signs of the hernial sac are broken - there will be no wall from the peritoneum.

The degree of the GVAP is determined in the diagnosis of the severity of the displacement of the stomach and esophagus in the chest cavity. Light( first degree) - does not cause any disturbances, since only two lower segments of the esophagus pass through the diaphragmatic space( intra- and sub-diaphragmatic).The size of the dilated esophageal opening does not give the possibility of "stretching" the stomach.

It is possible to develop inflammation( esophagitis, gastritis), but there is no pronounced symptom of digestive disturbance. The second degree - except for the esophagus, the upper part of the stomach leaves the hernial opening, but remains at the level of the esophageal dome of the diaphragm. The patient exhibits all the typical signs of GAP, belching and heartburn are especially troubling after eating.

Third degree - there is a movement in the chest cavity of a large part of the stomach, the sub-diaphragmatic zone of the esophagus, in the severe cases in the chest cavity the entire stomach is detected.

Diagnosis

Disease can not be assumed with complete certainty only on the basis of patient complaints and examination. The main objective methods for diagnosing pathology should be to establish precisely which organs and how far they move from the abdominal cavity to the thoracic cavity through the esophagus in the diaphragm. For this, the following are used:

• chest X-ray;
• examination of the esophagus and stomach with radiopaque substance;
• esophagoscopy - examination of the esophagus with a special apparatus( esophagoscope);
• fibrogastroscopy is a common way of revealing the internal problems of the esophageal mucosa and stomach with a flexible thin hose fitted with optics.

The main radiologic signs of GVAP: an abnormally high position of the lower segments of the esophagus with the transition to the chest cavity, the movement of the cardiac valve into the supra-diaphragmatic space, the dilated esophageal opening in the diaphragm dome, the stasis of contrast in the contents of the hernia.

Endoscopic studies reveal:

• inflammation of the stomach and esophagus;
• shortening of the esophagus due to spastic contraction;
• gaping of the cardiac sphincter or lack of tightness when closing;
• picture of reflux cast;
• displacement of the esophagus junction line with the stomach in the supra-diaphragmatic position;
• narrowing of the lower end of the esophagus.

When fibrogastroscopy is taken material for cytological examination of tissues, to exclude the possibility of tumor growth. To determine the tendency of the hernia to internal bleeding, a feces analysis is performed on Gregersen's reaction, the erythrocytes, hemoglobin of the blood are checked for anemia.

The method of esophageal manometry - allows to investigate the ability to reduce longitudinal and circular muscles of the esophagus, coordination of contractions of sphincters, peristaltic movements of the stomach.

Impedanceometry is a method of detecting the work of the esophagus and stomach by probing the electrical resistance between inserted electrodes. In order to simultaneously monitor the activity of the heart and upper digestive tract, gastrocardiomonitoring is used. The method combines recording ECG and acidity measurements.

By the method of pH-metry, the acidity of the gastric juice, the return to the esophagus, is studied. It is possible to compare the efficacy of the combined conservative treatment of hernia of the esophageal opening of the diaphragm without surgery.

Symptoms of infringement of

The infringement is explained by the jamming of organs passed through the hernial canal in an uncharacteristic place, the impossibility of returning. The main cause is sudden contraction of the muscles of the diaphragm or torsion of the hernial sac. There are much more painful symptoms than the background of the disease.

They are caused by a violation of blood circulation in the moved organs, tissue necrosis. The pains become cutting, intense, localized behind the sternum, are constant, irradiate into the back and abdomen. Heartburn is perceived as a burning sensation. Appears profuse belch, then vomiting. The abdomen is swollen, weakness is increasing. The body temperature rises, sometimes the patient is shivering.

In case of fibrogastroscopy performed at emergency indications, a discolored color change from gray-blue to black( gangrene) is detected. The patient should be operated immediately. Timely removal of jammed parts of organs is the only way to save lives.

Can I get rid of a herniated diaphragm without surgery?

Treatment of a hernia of the esophageal opening of the diaphragm depends on the degree of movement of the organs into the hernial opening, the presence of complications, concomitant diseases. At the first degree, the disease is detected accidentally, does not bother the patient, but to prevent further development of the pathology doctors advise:

• to adjust diet - from the menu all foods and dishes that cause increased fermentation, constipation, increase of gastric lavage, promoting weight gain should be excluded;
• to normalize weight is a long process that requires proper nutrition and physical activity, since not all exercises can be performed, only exercise gymnastics should be practiced, the complex should be chosen with the participation of a specialist;
• in everyday life will have to give up wearing heavy weights;
• to prevent the flow of gastric juice into the esophagus at night is recommended to sleep in a semi-sitting position, raise the head end of the bed.

In the photo, contra-indicated work in the forced inclined position of

After the examination, individual features of the flow, the primary mechanism of defeat, are revealed in each patient. This principle prescribes medicines. To reduce acidity and prevent defeat of the mucosa of the esophagus:

• antacids( Almagel, Gastal, Maalox);
• proton pump inhibitors( Pantoprazole, Esomeprazole, Omeprazole);
• antihistamines( Ranitidine).

Normalization of muscle contractions help prokinetics( Motilium, Motilac, Trimebutin).Vitamin funds of group B, purposefully influence nervous regulation of sphincters, zones of cardia, restore epithelial tissue.

Local painkillers( Almagel A) are recommended for pain relief, non-steroidal anti-inflammatory drugs( Ibuprofen, Nurofen) are prescribed less often, as they themselves can cause an inflammatory process in the stomach.

Folk remedies manage to maintain and strengthen drug therapy. Various vegetable decoctions perform the same functions as medicines, but less productive: seeds of dill and flax, chamomile flowers, licorice root, senna leaf. To adjust the organs that have passed up in the curative, it is recommended that patients jump from the top step to the lower step.

Sharp "landing" on the heels replaces jumping

How is surgical treatment performed?

With the second-third degree of the GPPO, only the operation can be effective. It is also used at an early stage, if there are no results from conservative therapy, the patient's digestive organs are severely damaged due to the hernia fault, the course of the disease becomes more complicated, with fibrogastroscopy, signs of precancerous mucosal lesions are revealed.

The extent of the intervention depends on the size of the hernia gates and the condition of the displaced areas of the esophagus, stomach, and gut. The least traumatic is the execution of suturing the sprained ligaments of the diaphragm, strengthening the esophagus-diaphragmatic ligament with the help of plastics( with their tissues or implantable mesh).In specialized clinics, laparoscopy is used for this purpose, which makes it possible to shorten the time for complete recovery.

In more severe cases, in the presence of complications, infringement, in addition to plastic, produce:

• fundoplication - strengthening the sphincter, the place of connection of the stomach with the esophagus by wrapping the bottom of the stomach and fixing it to the ventral part of the esophagus;
• gastropexy - fixing( strengthening of fixation) of the back wall of the stomach to the peritoneum;
• resection of the esophagus and necrotic sites of the strangulated hernia.

Hernia of the esophageal opening of the diaphragm in a neglected state causes serious damage to digestion and the general condition of a person. It should be excluded when examining patients for other diseases. Timely preventive treatment and combating the root causes help avoid complications.