Axial hernia of the esophageal opening of the diaphragm

Axial hernia of the esophageal opening of the diaphragm is one of the varieties of hernial formations. Pathology has a significant spread among the population and follows the frequency of peptic ulcer and cholecystitis. Most often found in the elderly, only 19% falls on young age.

The name refers to the displacement of the contents of the hernial sac along the axis of the esophagus( axially).Treatment in the initial stages allows you to permanently get rid of unpleasant symptoms, prevent complications. It is important that with herniated protrusions of 1-2 degrees the signs of the disease are practically absent and the disease is revealed during a preventive examination or a referral to another doctor.

A bit about the participating anatomical structures of the

The human diaphragm is located approximately at the level of the lower edge of the ribs. This is a strong unpaired muscle, consisting of striated fibers. It separates the thoracic and abdominal cavities. It is directed by two domes upwards. For passage of the most important vessels, the nerve plexus and digestive tube forms the 3 main holes. The channel for food transport is located at level 10 of the spine. The course is formed by muscle tufts, which are called "medial legs".At the same time, the anterior vagus nerves are moving.

Diaphragm muscles assist the digestive organs in promoting food( the muscle ring in the hole serves as pulp).In addition, they:

• support gastric motility;
• , contracting simultaneously with the abdominal muscles, reduce intra-abdominal pressure.

Performing the functions of the aperture depends on its tone. In the stomach directly adjacent to the diaphragm, the departments are distinguished:

• cardial - the uppermost, in the area of ​​the esophagus;
• pylorus( antral part) - is the exit to the duodenum;
• bottom - a dome over the cardiac department;The
• body is the site between the cardial and gateway region.

All parts of the stomach are located in the abdominal cavity.

The hernia is formed by an abnormal ratio of the stomach and diaphragm when the lower part of the enlarged passage is able to penetrate into the chest cavity.

The mechanism of hernia formation

. According to the mechanism of hernia development, including the axial one, the

• congenital - the fetal abnormalities, the underdevelopment of the medial muscular legsdiaphragms with a violation of the formation of the closure ring, are detected in childhood;
• purchased.

A study of the mechanism of acquired hernia showed a value in the senile age:

• atrophic changes in the muscular ring;
• omission of the diaphragm, causing expansion of the esophagus;
• relaxation of the surrounding fascia.

On average and younger age, greater importance is:

• increased intra-abdominal pressure;
• decrease in the strength of the esophageal-diaphragmatic membrane, which fixes the position of the cardial part of the stomach and esophagus, its rupture, thinning leads to penetration of the cardia into the thoracic cavity.

Anatomically-physiological feature of sliding hernias is a violation of the obstruction for regurgitation( reverse movement of food).The esophagus-gastric connection below the diaphragm looks like an acute angle( called the angle of the Hyis).The apex of the corner forms a fold of the mucosa, which serves as a valve. Together with the muscular pulp of the cardiac department, it creates a mechanical obstacle to the regurgitation process.

Reasons for

Given the mechanism of development, axial hernia can result in:

• obesity;
• severe during pregnancy;
• injury and injury;
• increased physical activity;
• prolonged cough, including in smokers;
• increased intra-abdominal pressure in chronic constipation;
• wearing pulling clothes;
• gastritis with reflux;
• age changes;
• surgical intervention.

Varieties of hernias

There are many classifications of hiatal hernias( hiatal).The most common practical selection of three types:

• sliding( axial) - are marked by mandatory movement of the lower part of the esophagus of the adjacent stomach from the abdominal cavity to the thoracic and back;
• para-esophageal( near the esophagus) - only the upper parts of the stomach pass through the diaphragmatic opening;
• combined - have signs of both kinds.

Peripheral hernias often impair

Slip hernias differ in their ability to self-correct vertically:

• to fixed ones - they do not move independently;
• non-fixed - when lifting from a horizontal position to a vertical position, all drop-down parts are returned to their place.

Among the sliding hernias on the abnormal mobility of separate parts of the esophagus and stomach are:

• esophageal - only the lower part of the esophagus passes into the hole;
• cardiac - the cardiac part of the stomach falls out;
• axial-cardial - after the esophagus, a part of the cardia enters the orifice;
• cardio-fundal - in the chest cavity part of the vault and cardiac department of the stomach.

According to the classification proposed by B. V. Petrovsky and N. N. Kanshin, the group is added depending on the volume of the displaced stomach:

• subtotal - a small part of the organ enters the hernial sac;
• total hernia - the whole stomach opens into the hernial opening.

Simultaneously, the esophagus is shortened. The axial hernia accounts for up to 90% of all cases. It is more common in older women. According to the mechanism of occurrence, sliding hernias distinguish:

• for pulsed - in the basis of pathology, age-related muscle atrophy, increased intra-abdominal pressure in chronic constipation, obesity, pregnancy;
• traction - are associated with reflex lifting of the esophagus in certain diseases( peptic ulcer, cholecystitis), shortening, it pulls the cardiac compartment of the stomach into the chest cavity, this process goes through the functional and organic stages.

How is the degree of hernial protrusion determined?

The degree of protrusion of the hernial sac depends on the transition to the chest of the adjacent parts, it is revealed by the radiological method:

• the first - above the diaphragm is located only the final part of the esophagus, which is normally located inside the ring, the size of the hole prevents the wedging of the stomach, often accompanies peptic ulcer,the background of gastroduodenitis, diverticulum of the intestine;
• the second - the abdominal part of the esophagus and the upper part of the cardia of the stomach pass into the chest cavity;
• the third - in the hernial sac turn out to be both the abdominal part of the esophagus, and the whole stomach with its contents.

Symptoms

Changing the position of the organs leads to reflex disorders of the digestive process. The most characteristic symptoms are:

1. Pain syndrome is the main localization along the midline in the region of the angle connecting the ribs( epigastrium), in a squeezed manner. The intensity of pain varies, often radiating to the shoulder, back. Similar to a cardiac attack.
2. Heartburn - concomitant with pain, begins after eating or when moving( promote gastroesophageal reflux).Patients report an increase in lying position. The condition improves after taking milk, a solution of soda, walking.
3. Swallowing( dysphagia) is unstable, there is a difficulty in swallowing dry food( "a lump"), pain while passing food through the esophagus, belching. Often associated with concomitant esophagitis. It can last several years.

Pain provoked by food intake, physical activity

Less common:

• drooling;
• nausea and vomiting;
• long hiccough;
• feeling of bitterness in the mouth;
• hoarseness of voice.

Complications of

The most frequent complication and manifestation of sliding hernia of the esophageal opening is reflux esophagitis, which is caused by casting up gastric contents. In addition to it, the patient may have:

• peptic ulcer of the esophagus;
• cicatricial changes( strictures) with narrowing of the esophagus;
• bleeding from the veins of the hernial portion;
• shortening of the esophagus;
• Barrett's esophagus( replacement of a multilayer epithelial covering from flat forms of the esophageal epithelium with single-layered cylindrical cells from the stomach or intestine), precancerous disease.

Diagnosis

The main signs of the disease are determined by X-ray examination. To identify the abnormal location of the end of the esophagus and stomach use:

• a survey visual X-ray study with contrasting of the primary digestive organs - is currently rarely used;
• radiography( a series of images) of the esophagus and stomach.

Patient is taking pictures in position:

• lying,
• standing,
• on its side,
• in the elbow position of Trendelenburg.

Radiologists take into account, as a direct sign - a clear displacement of the stomach part of the chest cavity. The indirect ones include:

• a disturbed form of the gas bubble or its absence, a change in magnitude;
• angle increase;
• signs of reflux content casting;
• movement of the esophagus, reverse the right peristalsis.

Specialists in ultrasound diagnostics consider it possible to participate in the survey, the picture differs from the radiologic signs( on the right)

On esophagogastroscopy,

• visible walls of the esophagus are visible in the diaphragmatic area( picture of "gaping cardia");The
• cardiac compartment is located above the usual by shortening the esophagus;
• gastroesophageal reflux;
• foci of growth of foreign epithelium.

Additional methods include:

• , esophagogomanometry,
• scintigraphy,
• , intestinal pH measurement.

Conducting a general clinical examination helps identify complications:

• stool analysis can detect early signs of bleeding;
• blood test shows anemia, infection;
• ECG - necessary to exclude atypical angina.

Differential diagnostics are always performed:

• with different types of diaphragmatic hernias;
• cicatricial changes in the esophagus;
• peptic ulcer;
• malignant neoplasm;
• disorders associated with increased pressure in the portal vein;
• angina pectoris;
• cholelithiasis.

Conservative treatment of

Refusal of therapy of diaphragmatic hernia dramatically increases the risk of cancer in the next 5 years. The peculiarity of tactics for axial hernia of the diaphragm is the absence of urgent indications for surgical treatment, which is explained by the clinical course:

• this type of hernia is not infringed;
• can be successfully treated conservatively.

The tasks of conservative treatment are:

• prevention of gastroesophageal reflux;
• suppression of acidity of gastric juice;
• restoration of impaired esophageal and gastric motility;
• therapy of reflux esophagitis.

Regimen and diet

Patient recommendations for diet and regimen should be kept by patients constantly. It is necessary to exclude lifting of weights, performance of intensive work, wearing tight clothes, smoking. Sleep should be with a raised head end.

Nutritional rules remain for life

Fulfillment of nutritional requirements helps to reduce symptoms:

• food should be gentle in terms of machining( only steam dishes, wiped, scrolled in a meat grinder);
• the feeding frequency should be up to 6 times a day, in the evening you can eat 4 hours before bedtime;
• are unacceptable sharp, smoked, salted, fried dishes from fatty meat, sauces and seasonings( mustard, pepper, mayonnaise);
• excludes alcohol, carbonated drinks, sour juices, strong coffee and tea.

Medications

From medicines used:

• preparations, normalizing the acidity of gastric juice( Almagel, Maalox, Gastal);
• means regulating motor( prokinetics) and affecting the mucous membranes of the esophagus and stomach( Ganaton, Motilium, Trimebutin, Motilak);
• group of proton pump inhibitors( esomeprazole, omeprazole, pantoprazole);
• H2-antihistamines( Ranitidine);
• from the group of vitamins are especially shown B1, B6, B12;
• for non-steroidal medications are prescribed( Ibuprofen, Nurofen).

Tablets should be treated with caution. In acute cases, injections are preferred, because the absorption is impaired due to changes in the mucosa. In addition, there may be a negative effect of drugs.

When is surgery needed?

Indications for surgical treatment:

• no results of the effect of conservative therapy, persistence of the patient's severe symptoms;
• cases of severe reflux esophagitis with bleeding, ulcers, anemia;
• presence of cicatricial narrowing of the esophagus;
• with gastric hernia of large size( subtotal and total);
• combination of a sliding hernia with other diseases of the digestive system( ulcerative, gallstone, tumors).

The most common fundoplication operation for Nissen. It consists in creating from the bottom of the stomach an extra cuff to strengthen the cardiac section of the esophagus. At the same time, it is fixed to the pre-sewn legs of the diaphragm. In the modern version, the operation is performed by a laparoscopic method. Varieties of technology in operations in Balsi, according to Hill, according to Allison, are at the site of the incision, approaching the zone of hernial protrusion.

After surgical treatment, the patient is obliged to deal with the prevention of a re-emergence of a hernia. For this it is necessary: ​​

• to lose excess weight;
• to do gymnastics;
• to follow diet and diet;
• to cure the existing diseases of the digestive tract;
• not to allow constipation.

Adherence to a healthy diet and a balanced diet will help prevent digestive disorders and axial hernias.