Diaphragmatic hernia

Introduction Diaphragmatic Hernia refers to the internal organs of the abdomen through the weak pores of the diaphragm, defects or traumatic breaches into the chest. The sputum is divided into traumatic sputum and non-traumatic sputum, which can be divided into congenital and acquired. The most common non-traumatic sputum is esophageal hiatus hernia, thoracoabdominal hernia, parasternal hernia, and hernia. Esophageal hiatus hernia is the most common cause of more than 90% of the formation of esophageal hiatal hernia is controversial, a small number of patients with childhood onset of congenital developmental disorders, but in recent years, it is believed that acquired factors are the main, and Obesity is associated with increased intra-abdominal pressure. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: shock pleurisy intestinal obstruction

Cause

Increased intra-abdominal pressure (25%):

The difference in pressure between the thoracic and abdominal cavities and the activity of the intra-abdominal organs; various factors that cause increased intra-abdominal pressure such as bending, difficulty in defecation, and pregnancy can cause the abdominal organs to enter the chest through the diaphragmatic defect and the weak part.

Trauma (35%):

Chest trauma, especially combined with chest and abdomen injury, causes diaphragmatic injury, resulting in local weakness or even rupture of the diaphragm. In the case of elevated abdominal pressure, the abdominal organs break into the chest through this part.

Esophageal hiatus expansion factor (20%):

With age, the diaphragmatic muscles decrease and the esophageal ligaments relax, causing the esophageal hiatus to expand, and the sputum or corpus can penetrate the posterior mediastinum through the enlarged esophageal hiatus.

Congenital (15%):

Congenital diaphragmatic fusion is weak and weak, and in the case of elevated abdominal pressure, the abdominal organs break into the chest through this part. And caused embarrassment.

Prevention

To prevent postoperative complications, the following points should be noted:

1. Take a semi-recumbent position after waking to relieve the pressure of the abdominal organs on the diaphragm, which is beneficial to the healing of the diaphragmatic wound.

2. Continued gastric decompression after operation to prevent abdominal distension from compressing the diaphragm.

3. Before the recovery of bowel movement, intravenous infusion, appropriate amount of potassium. After the anus is exhausted, the gastric decompression tube is removed, and the airflow is inflated.

4. Encourage patients to cough, ultrasonic atomization and inhalation to prevent respiratory complications.

5. Keep the chest drainage tube open to prevent the healing of the diaphragm repair due to pleural effusion.

6. Regular application of antibiotics to prevent infection.

Complications Complications, shock, pleurisy, intestinal obstruction

Toxemia, shock, pleurisy, intestinal obstruction.

Symptoms common symptoms abdominal pain cyanosis chest pain chest pain with cold sweat chest pain with dyspnea upper central wall defect of the abdominal wall

Because the ectopic organs of the abdominal cavity enter the thoracic cavity, the negative pressure state in the thoracic cavity can be changed, and the lung tissue is compressed, resulting in displacement of the mediastinum. Acute cases can cause obvious acute dyspnea, hypoxemia, etc., and severe cases often cause death. Chronic patients may have no obvious clinical manifestations but only manifest as mediastinal masses, some may cause intestinal obstruction, and the intestines are narrowed and symptoms appear.

1. Traumatic spasm: the patient's symptoms are more serious. In addition to the symptoms of chest trauma, it can be accompanied by rupture of the abdominal organs causing bleeding, perforation and severe contamination of the chest and abdomen. The left diaphragm is ruptured, and the underarm organs can be inserted into the chest through the cleft palate, causing severe chest pain and can be radiated to the ipsilateral shoulder and upper arm, sometimes with upper abdominal pain or abdominal muscle tension. Due to the intrusion into the internal organs of the chest, the lung tissue and the heart are compressed, and the mediastinum is displaced to the contralateral side, so that the lung volume is significantly reduced, the patient has shortness of breath and difficulty in breathing, and in severe cases, there is purpura, and the heart shift causes the large vein to return to the blood. The flow is blocked, the stroke volume is reduced, causing an increase in heart rate, a drop in blood pressure, and even a state of shock. If obstruction or strangulation occurs in the internal organs of the chest, obstructive symptoms such as abdominal pain, bloating, nausea and vomiting, and hematemesis and blood in the stool may occur. In severe cases, toxic shock may occur. Physical examination revealed that the affected side of the chest was percussed with dullness or drum sounds, the breathing was weakened or disappeared, and bowel sounds were sometimes heard.

2. Congenital spasm: mainly varies according to the position and size of the ankle, the contents of the ankle, and the changes in the function of the internal organs. The parasternal hiatus is less likely to have symptoms after adulthood, mainly due to upper abdominal pain, fullness discomfort, loss of appetite, indigestion, intermittent constipation and bloating. These symptoms are easily overlooked and misdiagnosed as digestive tract. Disease, occasional X-ray examination, can be found in the presence of gastric vesicles and intestinal curvature behind the sternum and was diagnosed. If invagination occurs in the small intestine or colon, it can produce clinical symptoms of acute intestinal obstruction or intestinal stenosis.

Awkward inspection

1, chest positive lateral examination

The irreversible esophageal hiatus hernia shows the sacral cavity in the mediastinum and the posterior part of the heart shadow on the positive lateral chest radiograph; the parasternal hernia can also be shown as the dense dense shadow of the right palpebral angle. The thoracic and peritoneal hiatus hernia shows a honeycomb translucent shadow in the left lung field and is continuous with the abdominal intestinal gas; the parasternal hernia shows a gas-filled or solid mass shadow in the right palpebral horn; X-ray signs of traumatic hernia It is the stomach bubble in the left thoracic cavity, and the gastric gas continues to the abdomen.

2, barium meal inspection

Sliding esophageal hiatus hernia shows enlargement of esophagogastric angle, widening of lumen of vestibular section of gastroesophageal tract and upturn of cardia; irreversible esophageal hiatus hernia shows an enlarged upper esophageal sac under short esophagus; thoracic peritoneal hernia shows stomach And part of the small intestine into the left thoracic cavity; the parasternal hernia showed that the colonic hepatic sputum into the right thoracic cavity, the intestines of the hernia sac neck close together; traumatic hernia showed that part of the gastric cavity broke into the left thoracic cavity.

3, chest CT plain scan

Traumatic sputum showed chest pain at the level of the chest. The contour was smooth. When the contrast agent was used, there was a positive contrast agent in the gastric vesicle. The CT sign of the esophageal hiatus hernia was the image of the gastrointestinal tract in front of the esophagus.

Diagnostic diagnosis

diagnosis

Combined with clinical manifestations, physical examination and X-ray examination with X-ray examination of the transverse congenital defect can make a diagnosis.

Differential diagnosis

Esophageal hiatus hernia is mainly due to the clinical symptoms caused by its complications need to be identified with other diseases.

(1) acute ventricular episode infarction and angina pectoris: the age of onset of esophageal hiatal hernia is also a good age for coronary heart disease, chest pain associated with reflux esophagitis patients can be similar to angina pectoris, can be radiated to the left shoulder and left arm, containing nitroglycerin It can also relieve symptoms. However, patients with general reflux esophagitis have lower chest pain and a burning sensation, which often occurs after a meal and a peaceful sleep. Angina pectoris is often located behind the middle sternum and often occurs after physical activity with little burning sensation. Sometimes the above two conditions can exist at the same time, because the vagus nerve impulse from the hernia sac can reflexively reduce coronary circulation blood flow and induce angina pectoris, so the above possibility should be considered in clinical analysis. Continuous dynamic electrocardiogram observation and myocardial enzyme detection are helpful for differential diagnosis.

(2) Lower esophageal and cardiac cancer: prone to occur in the elderly. Invasion of the lower end of the esophagus by cancer tissue can cause gastroesophageal reflux and difficulty swallowing, and should be alert to this disease.

(3) Chronic gastritis: There may be symptoms such as upper abdominal discomfort, acid reflux, heartburn, etc. Endoscopy and upper digestive tract barium meal examination are helpful for identification.

(4) Peptic ulcer: The effect of acid suppression treatment is obvious, and the reaction is similar to that of symptomatic esophageal hiatus hernia. Symptoms such as upper abdominal discomfort, acid reflux and heartburn usually occur on an empty stomach, and have nothing to do with body position changes. Endoscopy can confirm the diagnosis.

(5) Respiratory diseases: Patients with esophageal hiatal hernia may have symptoms of respiratory diseases such as cough, cough, wheezing, belching, etc. X-ray CT examination is helpful for differential diagnosis.

(6) biliary tract disease: In addition to upper abdominal discomfort, generally there may be manifestations of inflammatory diseases, such as fever, increased white blood cells, bile duct stones with cholangitis, many patients with jaundice, physical examination of the right upper abdomen may have localized tenderness, blood biochemistry Examination, B-ultrasound and CT scans help to differentiate the diagnosis.

(7) gastric perforation: the upper abdomen is persistent knife-like pain, abdominal muscle tension, with or without hernia, acid reflux, nausea, vomiting, but the peritoneal dialysis is free of sputum and gas. A sac.

(8) exudative pleurisy: left lower chest and left upper abdomen obvious pain, left chest breath sounds weakened, percussion dullness, X examination showed: left pleural effusion, but careful auscultation of the chest can be heard and bowel sounds, barium meal examination can be found There is a full stomach in the chest.

(9) left pneumothorax: the heart is shifted to the right, the heart sound is far weak, the left upper chest is diagnosed with drum sounds, the lower chest is diagnosed with voiced sounds, the vocal fibrillation is weakened, the breath sounds are weakened, and the chest is open to the left chest with gas and fluid signs, according to the chest cavity. Gas and fluid signs can be identified with pneumothorax. The area where the percussion is drum sound, the vocal fibrillation is weakened, and the breath sound is weakened is mostly the gourd shape in which the stomach is invaded into the chest cavity, and the gas is filled with gas to cause the stomach to expand extremely.

(10) intestinal obstruction: abdominal pain, abdominal distension, nausea, vomiting, disappearance of bowel sounds, or the sound of gas over water, mostly due to obstruction caused by the transverse colon into the chest cavity, sputum through the chest cavity filled with intestinal tract.

(11) Concomitant disease: Saint triad: refers to the presence of both sputum, cholelithiasis and colonic diverticulum. Some people call this triad associated with old age, excessive diet and constipation, and increased abdominal pressure. Casten triple sign: refers to the simultaneous presence of sliding hiatal hernia, gallbladder disease and duodenal ulcer or esophageal ulcer. The causal relationship between the above two triads is still unclear and should be considered in the differential diagnosis.

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