The diaphragmatic hernia
With a diaphragmatic hernia there is a condition in which parts of the abdominal organs are displaced into the chest cavity. In general, a distinction must be made between so-called real diaphragmatic hernias and a diaphragmatic defect. The difference is that in a true diaphragmatic hernia, the abdominal organs are surrounded by a hernial sac, whereas in a diaphragmatic defect this is not the case.
A diaphragmatic hernia is caused by a weak point in the diaphragm and can be both congenital and occur in the course of life (for example after an accident). There are a number of typical weak points where diaphragmatic hernias are particularly common. For example, hernias are common, which find their way into the chest cavity through a gap in the back of the diaphragm. This gap is also known as the Bochdalek triangle.
Hernias on the right diaphragm often lead through the so-called Morgagni hole, while the so-called Larrey fissure represents the point of passage on the left side of the diaphragm. Both gaps normally serve as a passage for blood vessels. Even where the esophagus or the main artery (aorta) pass through the diaphragm, parts of the abdominal organs can pass through the diaphragm and form a hernia.
Causes of the appearance of diaphragmatic hernias
The causes of the appearance of diaphragmatic hernias can be different. In general, a distinction must be made between a congenital and an acquired diaphragmatic hernia.
Congenital hernias often occur due to a developmental disorder of the diaphragm. If the child's diaphragm development is disturbed during pregnancy, abdominal organs can be in the chest cavity from birth (elevated diaphragm). The exact cause why the diaphragm develops incorrectly is in most cases unclear. However, an increased probability of the occurrence of diaphragmatic hernias in certain genetic defects could be determined.
Acquired diaphragmatic hernias can occur due to a variety of causes. These hernias are particularly common after serious accidents and injuries. In many cases, an individual weakness of the diaphragm, along with other risk factors, is responsible for the development of the hernia. For example, hernias can arise when the internal pressure in the abdomen increases, for example when the abdominal muscles are tensed and the bowels are pressed hard. Pregnancy and being very overweight can also increase the risk of developing a diaphragmatic hernia. If the diaphragm is injured from an accident or injuries such as stabbing or gunshot wounds, a resulting hernia is also possible.
Diaphragmatic hernia in the infant
Diaphragmatic hernias that occur in infants are also called congenital diaphragmatic hernias designated. These usually occur for no explainable cause. However, it has been shown that hernias are slightly more common in children with a genetic defect than in children without a genetic defect. As a rule, children with a congenital diaphragmatic hernia need after birth intensive medical care and be operated on as soon as possible.
The prognosis of congenital diaphragmatic hernia varies depending on the impairment of lung development and function. However, an operation that repositions the organs below the diaphragm and repairs the defect is often successful in children who have adequate lung development.
Diaphragmatic hernias in pregnancy
The increased pressure in the abdomen in pregnant women can occasionally be the reason for a diaphragmatic hernia. The digestion usually suffers from the lack of space during pregnancy. However, whether a diaphragmatic hernia has developed can usually only be determined after pregnancy, when the body slowly normalizes.
Because most diaphragmatic hernias are asymptomatic, some diaphragmatic hernias that develop during pregnancy are never diagnosed. However, if it causes discomfort, the post-pregnancy hernia is treated the same as any other.
Increased pressure in the abdomen during pregnancy can cause not only a diaphragmatic hernia but also an umbilical hernia. You can read more about this in the next article: Umbilical hernia in pregnancy
Localization of a diaphragmatic hernia
Diaphragmatic hernias can occur in different parts of the diaphragm. Typically, hernias develop at characteristic weak points of the diaphragm.
The most common hernia on the diaphragm is located at the point of passage of the esophagus, which is positioned slightly to the left of the diaphragm. The symptoms of this hernia are also mostly felt on the left side, since the stomach usually pulls through this gap and causes problems on the left.
The left side is also more often affected by a hernia, as the liver is located under the right diaphragm and prevents the abdominal organs on that side from moving upwards. The left diaphragm is also less protected from external violence from accidents or cuts, which therefore more often cause a hernia on this side.
Symptoms of a diaphragmatic hernia
A congenital diaphragmatic hernia is usually noticed in advance during ultrasound examinations and should be treated immediately after the birth. Children who are born with a diaphragmatic hernia are usually noticeable because breathing is very difficult. In some cases, adequate breathing is completely impossible due to the diaphragmatic hernia. If the lungs could not develop properly because of the organs in the chest cavity, the survival of the child after birth can be seriously endangered or impossible.
An acquired diaphragmatic hernia can have different symptoms. This depends primarily on the extent of the hernia as well as the accompanying diseases and the affected organs. Most often, the stomach crosses through the gap in the diaphragm. This can lead to reflusx symptoms (heartburn) and stomach pain. Bad breath and vomiting are also possible as part of this hernia. Symptoms of the heart as well as breathing difficulties and pain in the diaphragm can occur, especially after meals.
It should be noted that in many cases diaphragmatic hernias proceed unnoticed and without symptoms.
Read more on this topic at: Symptoms of a diaphragmatic hernia
What pain does a diaphragmatic hernia cause?
A diaphragmatic hernia is less likely to cause direct pain. If so, they occur in the epigastrium, the area between the stomach and the heart.
More common, however, is heartburn, which manifests itself as a burning pain behind the breastbone. In the extreme case of the thoracic stomach, in which the stomach slips almost completely into the chest, the displacement of the heart can also lead to heart attack-like pain symptoms
Also read the article: Heartburn symptoms.
Diagnostic procedures for a diaphragmatic hernia
A congenital diaphragmatic hernia is usually found during check-ups before the child is born. Ultrasound examinations can determine relatively precisely to what extent the hernia affects the development of the child and which measures should be carried out as a priority immediately after the birth.
In the case of acquired diaphragmatic hernias, the anamnesis comes first in the diagnosis. The symptoms described can substantiate the suspicion of a diaphragmatic hernia and help determine the next diagnostic steps.
However, in order to be able to diagnose a diaphragmatic hernia with certainty, an imaging examination is usually carried out. With the help of an ultrasound and especially an X-ray examination, a diaphragmatic hernia can often be reliably diagnosed. During the X-ray examination, a certain contrast agent must be taken so that the crucial areas can be reliably depicted. In the X-ray image, the bowel or stomach sections that are located above the diaphragm can be clearly shown. The location of the hernia can also be clearly seen in the X-ray.
Examinations with the help of an MRI are also well suited, although this is usually only used for special questions due to the effort and costs.
A congenital diaphragmatic hernia occurs in about 1 in 2500 children.
Acquired diaphragmatic hernias usually occur on the left side and often after serious accidents and injuries, with around 10,000 diaphragmatic hernias occurring throughout Germany each year.
Therapy of a diaphragmatic hernia
A diaphragmatic hernia is often treated with surgery. This is particularly the case with congenital diaphragmatic hernias. Acquired hernias that occur in the course of life are operated on if symptoms occur and these cannot be treated with conservative methods.
In many cases, surgery must be performed to prevent entrapment of the bowel, which can lead to serious complications. If there are already complications and insufficient blood supply to individual sections of the intestine is possible or threatened, an operation should be performed as soon as possible.
Different surgical techniques must be used depending on the location and cause of the diaphragmatic hernia. In most cases it is a so-called hiatal hernia, in which the stomach passes through the diaphragm. This is brought back into the optimal position during the operation. To prevent the stomach from moving up again, the diaphragmatic gap is made smaller and stabilized with a specific surgical technique. To prevent the stomach from moving again, it is sewn to the underside of the diaphragm. Another option is to loop the stomach around the esophagus below the diaphragm and fix it either to itself or to the esophagus. This technique is mostly used when heartburn and reflux are the main symptoms.
Congenital diaphragmatic defects may be closed with a mesh and sewn more tightly.
Are you about to have an operation and want to find out more about it? Read our next article below: Risks of anesthesia
Prognosis of a diaphragmatic hernia
The prognosis of a diaphragmatic hernia is usually very good. For example, many hernias that do not cause any symptoms do not require therapy. The success of the operation can be assessed as very good, with most patients being symptom-free after the operation.
Congenital diaphragmatic hernias have a less favorable prognosis. The prognosis for these hernias is primarily determined by the impairment of lung function. In the case of a large hernia and the associated severe impairment of lung development, the prognosis is poor. The affected children usually have to undergo pediatric surgery immediately after birth. However, since the restriction is often limited, the operation is successful in many cases. The survival rate varies depending on the clinic and is up to 90% of the operated children.
What are the chances of survival with a diaphragmatic hernia in the baby?
In babies with congenital diaphragmatic hernia, the survival rate depends heavily on various factors. The severity of the hernia plays one of the most important roles, i.e. the exact location, size and which organs have slipped into the chest.
The larger the contents of the hernial sac, the less space the lungs have to develop in the womb (so-called pulmonary hypoplasia). When the child is born, the underdeveloped lungs cannot supply the body with sufficient oxygen and the newborn has shortness of breath. Surgery is always necessary to close the defect.The children recover from this in 60-80% of cases, depending on the specialization of the children's clinic.
What can be the long-term consequences of a diaphragmatic hernia?
Without surgical treatment of an acquired diaphragmatic hernia, the crushed organs, especially the stomach and heart, are damaged. The stomach lining is permanently irritated by the constriction, it can lead to ulcers. The heart also suffers from being displaced by the stomach, which can manifest itself in a faster heart rate, cardiac arrhythmias and heart attack-like symptoms (so-called Roemheld syndrome). The esophagus, which is permanently attacked by stomach acid, can also become inflamed. In the worst case, esophagitis can even degenerate into carcinoma of the esophagus.
The long-term consequences after an operation are usually the same, regardless of whether they are congenital, acquired or traumatic diaphragmatic hernia. The closure of the diaphragmatic hernia, which was artificially carried out by surgery, can open again and require another operation. Such a relapse is quite common.
Another classic consequence after surgical treatment of the diaphragmatic hernia is a tightness at the junction between the esophagus and the stomach. This can be expressed by the feeling that the bite is literally stuck in the throat (or in the chest, namely in front of the stomach entrance). Another phenomenon of the new bottleneck is the so-called gas bloat syndrome. Patients are no longer able to burp to get rid of excess gas in the stomach. Many patients find this very uncomfortable, as the gas collects in the stomach.
Is Diaphragmatic Hernia Hereditary?
No, a diaphragmatic hernia is usually not hereditary. Although genetic causes for the development of congenital diaphragmatic hernias can be found in infants, hereditary factors would mean that there are more diaphragmatic hernias in the families of the children concerned. This is not the case.
Acquired diaphragmatic hernias, such as the hiatal hernia, in which the stomach slips into the chest, are almost never genetic, but mostly due to an unhealthy lifestyle (overweight, low-fiber diet). In rare cases, hereditary diseases associated with weak connective tissue can be an exception. In these cases, however, other clinical pictures are usually in the foreground.