Do not underestimate the diaphragm disease. According to scientists, this organ is the second heart of the human body. If a person is healthy, for each minute he performs about 18 motor acts, shifting from the starting point up and down by 4 cm. The diaphragm is the strongest human muscle that compresses the vascular system of the abdomen, lymphatic vessels. Thanks to it, the veins are emptied, the blood penetrates the chest.
general information
It is sometimes difficult to notice diseases of the diaphragm of a person, but some pathologies immediately manifest themselves as severe symptoms. All diseases of the body adversely affect its performance. Normally, a muscle contracts per minute four times slower than a heart. It provides a powerful blood pressure - much higher than guaranteed by the heart muscle tissue. This is due to the large area of the organ and the ability to strongly push blood.
With a certain periodicity, the diaphragm compresses the liver, making the bile flow easier and more accurate. At the same time, the muscle stimulates blood flow in the liver. The better the diaphragm works, the better the liver functionality, and this has a positive effect on the condition of a person suffering from various diseases. The converse is also true: if the diaphragm does not work well, the functionality of all vital organs of the body deteriorates.
Problems: Damage
For some diseases of the diaphragm, surgery is the most effective way to help those in need. This is often the case with organ damage. Closed damage is possible due to an injury at work or on the road. A person can fall from a great height, get a shell shock. The cause of the damage can be strong pressure on the stomach. An organ rupture is usually due to a sharp increase in pressure in the abdominal cavity. In most cases, lesions are localized in the tendon center or nearby, as well as in the place where the tendons pass into the muscle fibers.
Up to 95% are cases of violation of the integrity of the left dome of the organ. Damage is accompanied by injuries of the pelvic bones, the integrity of the chest may be impaired. Damage to the diaphragm often leads to a violation of the structure and integrity of organs localized in the abdominal cavity. A wound, a rupture of a muscle organ due to negative pressure in the sternum, leads to a displacement of the stomach into the pleural region. The omentum shifts, intestinal sections, the liver move. The spleen may be affected.
Open option
Such a diaphragm disease is possible when a wound is received. More often it is a cut, stab wound. The cause may be a thoracoabdominal wound obtained from a firearm. From statistics it is known that such damage is almost always accompanied by other violations of the integrity and structure of internal organs. Mostly affected are organs located in the sternum, abdomen.
Clinic and Clarification
If damage to the X-ray diagnosis of diaphragm disease is suspected, this is the main method for assessing the patient's condition. At the acute stage of development, manifestations of trauma are observed. The patient is in a state of shock. Fixed weakness of the respiratory system, vascular, cardiac. Bleeding is usually fixed, bone fractures are possible. If the diaphragm is damaged, there is usually hemopneumothorax, peritonitis.
In the diagnosis, it is necessary to evaluate the compression, displacement of the mediastinal internal organs. Sometimes structures falling into the pleural zone are infringed. The doctor’s task is to discover this fact in time. To do this, resort to x-ray radiation.
What to do?
Treatment of diaphragm disease on the background of a wound, a gap involves surgery. Urgent surgery is indicated. Need to sew up defects. The doctor imposes separate sutures, resorting to material that is not able to absorb. Previously, the abdominal organs are returned to the place. The first stage of the operation is thoracotomy or laparotomy. The choice in favor of a specific option is due to the characteristics of the injury received by the patient.
Hernia
This term refers to a pathological condition in which organs, normally located in the abdominal cavity, are displaced into the sternum. By moving, defects become available that a person has from birth or subsequently acquired due to aggressive factors. All cases of hernia are classified as acquired, congenital, due to injuries. False forms of the disease are known. This is the name of the condition in which the pathological bag is absent in the peritoneum. Such pathologies are also available from birth, acquired. The first appear if in the diaphragm separate areas characteristic of the embryo remain overgrown. At this stage of human development in the muscle structure, there are special ways of communicating cavities (sternum, abdominal). Normally, as a person develops, they overgrow. Cases of pathology are relatively rare.
A more common diaphragm disease is a false type hernia obtained due to trauma. It is often explained by a wound of internal organs, actually the muscle. A preceding isolated diaphragm rupture is possible, the dimensions of which do not exceed three centimeters. This can appear not only in the muscle block of the organ, but also in the tendon zone.
True hernia
A distinctive feature of this pathological condition is the presence of a hernial sac. It covers organs displaced relative to the normal anatomical position. Such a disease of the diaphragm is usually observed against a background of increased pressure inside the abdominal cavity, which leads to a displacement of the organs located in it. If they pass through the sterno-costal area, a parasternal hernia is diagnosed. More often pathological conditions are identified, named after the researchers: Morgagni, Larrey. Perhaps the passage of internal structures through poorly developed sections of the diaphragm of the sternum. In this case, a retrosternal hernia is diagnosed. If the internal organs are moved from the anatomically correct position through the lumbar-rib sections, a Bohdalek hernia is revealed.
And in the case of congenital pathology, and with another variant of the disease, the hernial sac contains internal organs. These may include oil seal, fiber. The latter is called parasternal lipoma. Atypically located true variants of diaphragmatic hernia in medicine are very rare. They are somewhat similar to diaphragm relaxation. The key difference is the appearance of hernial gates, which is accompanied by a potential risk of infringement.
State Clinic
Symptoms of diaphragm disease vary from case to case. Much is determined by the level of displacement of internal elements in the pleural block. The scale of the manifestation of the pathology is determined by the volume of the moving parts, the level of fullness of the hollow structures. Bending, squeezing plays a role - this is usually observed near the gates of the pathological zone. The clinical picture is dictated by pulmonary collapse, mediastinal displacement. A lot is determined by what the gates are, how big they are, what kind of configuration they have. It is known that false pathologies sometimes in principle do not have pronounced symptoms. All manifestations are divided into general, associated with the respiratory, cardiac system and gastrointestinal tract.
The symptoms of diaphragm disease in a person include a feeling of weight in the stomach. The patient may notice pain in this area. Sensations spread to the chest, under the ribs. There is an increase in speed, a worsening of the heartbeat, shortness of breath is fixed. Symptoms are especially pronounced if you eat tightly. Gurgling and rumbling are often felt in the sternum. Symptoms are noticeable in half where the hernia is located. If the patient lays down, the symptoms are activated. Following the meal, vomiting is possible when the food has just entered the body. If a gastric inversion is observed, the esophagus is bent, specific dysphagia forms, large parts of the food move along the gastrointestinal tract much better than liquid.
Features of manifestations
Symptoms of a diaphragm disease in a person include soreness that occurs with attacks. This is observed if the hernia is infringed. Sensations are localized in the area of the sternum where the infringement occurred. Pain in the epigastric zone is possible, if there is an infringement in this place. There is a likelihood of symptoms inherent in acute bowel obstruction. If the hollow structure is infringed, the start of necrotic processes, wall perforation is possible. The result is pyopneumothorax.
An initial diagnosis can be made if the patient has previously been injured. An important role in the formulation of the diagnosis is played by patient complaints and worsening sternum mobility, smoothing the gaps between the ribs from one half of the body. Doctors involved in the diagnosis, clinic, treatment of diaphragm disease, note that in many patients with such a hernia, the abdomen sinks. This is more typical of the case of the continued existence of pathology, the large dimensions of the process. Over half of the sternum corresponding to a hernia, dullness, tympanitis are observed, the intensity is determined by the fullness of the gastrointestinal tract. The task of the doctor is to listen to intestinal motility. Possible splashes, noises, weakness of respiratory noise, its disappearance. Mediastinal dullness can move to unaffected areas.
Instrumental examination
Before formulating a conclusion, it is necessary to do an X-ray diagnosis of the diaphragm disease. Additionally, sometimes a CT scan is required. If the gastric cavity has shifted to the sternum, there is a high horizontal fluid level on the left side. When the small intestine falls out, studying the field of the lungs shows areas of shadow, light. The displacement of the liver, spleen on an X-ray is reflected in a darkened area of the lung field. In some patients, the diaphragm dome and the abdominal organs that extend above it are clearly visible.
Sometimes a contrast x-ray of the gastrointestinal tract is recommended. This may indicate parenchymal internal organs have fallen out or are hollow. In the study, the exact position of the hernia gate, their dimensions, is determined. They repel information on the compression of displaced regions. Sometimes pneumoperitoneum is needed to make an accurate diagnosis. If the hernia is false, the air moves to the pleural zone. With an X-ray examination, the result will be consistent with pneumothorax.
Therapy
With the above symptoms, the treatment of diaphragm disease is practiced surgical (there is a high risk of infringement). If the pathology is localized in the right half of the trunk, the operation is transthoracic. The parasternal scenario requires an upper laparotomy. If the pathology is localized on the left, transthoracic access is required. First, the adhesions are separated, then the edges of the defective area are released, the zones that have risen from there are reduced to the peritoneum, then the damaged diaphragm block is sutured. Nodal joints are required. These should be separate. The surgeon's task is to make a duplicate. Sometimes the defect is very large. This requires the use of synthetic products to block it. Use made of lavsan or teflon.
If a retrosternal hernia is established, Larrey, organs displaced from the laid blocks are transferred below, then the bag is turned out and cut off. The next stage is the formation of seams in the form of the letter "P" with subsequent tying. Defective edges are treated this way, then the posterior vaginal sheet of the peritoneal muscles. The next stage of the surgeon's work is the processing of ribs, sternal periosteum.
Nuances and Cases
If, with the above symptoms of the disease, the treatment of the diaphragm is necessary against the background of a pathology localized in the lumbar-rib section, separate sutures are made for suturing the diaphragm defect. The task of the doctor is to form a duplicate.
If the hernia is impaired, transthoracic access is required. The constricting ring is dissected. The next step in the work of the doctor will be to study the filling of the hernial sac. If the prolapsed organs are still viable, they need to be set in the peritoneum. If the changes are irreversible, the affected areas must be removed. The final step is suturing a defect in a muscle organ.
Esophageal hernia
Such a disease of the diaphragm can be obtained during life or inherited from birth. All cases are divided into paraesophageal, axial. The latter are also called moving. In fact, such a pathology is a protrusion of the gastric cavity through the opening of the esophagus, anatomically provided in the diaphragm. The main percentage of cases of such a disease does not have pronounced symptoms. If acid reflux worsens over time, manifestations characteristic of gastroesophageal reflux disease (GERD) are observed. An x-ray is shown to make a diagnosis. The patient must first take one sip of barium sulfate. The therapeutic course is chosen based on the symptoms of the case. Treatment is necessary if typical manifestations of GERD are observed.
The etiology of the pathology is still unclear. It is believed that a hernia appears as a result of sprain of the fascia of the diaphragmatic fissure, the esophagus. Most often, a sliding form of the disease is observed. The gastroesophageal transition in patients with this disease is above the diaphragmatic level, a certain percentage of the stomach is also located higher. If studies show a paraesophageal hernia, the transition is anatomically correct, a certain percentage of the stomach is adjacent to the esophagus inside the opening.
Case features
A hernia is an abnormal protrusion. Such a disease of the diaphragm in a sliding scenario is recorded in approximately 40% of people who came for a preventive study. The phenomenon is among the relatively widespread. More often it comes to light completely by accident when the patient is sent for an X-ray examination due to some other reasons. With this disease of the diaphragm, clinical recommendations are difficult to formulate because of the problems of determining the connection of symptoms and the fact of the presence of the disease. Statistical studies show that the majority of GERD sufferers have such a hernia. But among people who have found such a hernia, GERD is detected in less than half.
A sliding hernia is a disease of the diaphragm, the symptoms of which most do not manifest at all. Less commonly, patients report pain in the sternum. Other sensations indicating reflux are possible. If the pathology is formed paraesophageally, it does not manifest itself with any sensations. If we compare the course of the case with a sliding form, it should be noted the probability of pinching the opening of the esophagus. Therefore, there is a risk of complications in the form of strangulation. Any variant of hernia can provoke massive bleeding in the digestive tract, causing a hidden focus of bleeding.
Clarification and treatment
If, on the basis of symptoms of a diaphragm disease or without such at all, the doctor believes that it is necessary to check the patient for a hernia of the esophageal diaphragm opening, an x-ray examination is prescribed. Barium sulfate is used to ascertain. If the pathology is very large, it is more likely to reveal it completely by accident when the patient is sent for an x-ray examination of the sternum. If the pathological process is small, the only reliable modern detection method is fluoroscopy with the preliminary intake of barium sulfate.
If a sliding hernia is detected, there are no symptoms of the disease, and specialized treatment is usually not prescribed. If symptoms characteristic of GERD are observed, therapy is chosen based on this diagnosis. In case of diaphragm disease, hospital surgery is indicated only in the case of the paraesophageal type due to the probability of infringement. In the case of a sliding type of hernia, surgery is sometimes required if an internal bleeding site has formed. There is a possibility of complications in the form of peptic esophageal stricture, which also requires surgical measures. If GERD is not amenable to conservative therapy for a long time, surgery may be recommended.
Paraesophageal hernia: features
Such diseases of the diaphragm are divided into two categories: antrum, fundus. , . . , . . . - . - . .
Conducting sternal fluoroscopy allows you to detect the shadow of the heart with a rounded light block. Sometimes a liquid level is reflected. If the stomach contains a contrast agent, you can determine where and how the fallen block is located, how it is located relative to the cardia, esophagus. If the symptoms suggest a polyp, there is a suspicion of peptic ulcer or gastric oncology, esophagogastroscopy is necessary.
Diaphragm relaxation
This term refers to a pathological condition in which the diaphragm becomes thinner and shifts together with the organs located near it, while the fastening line often remains the original. Congenital cases of such a disease are possible due to underdevelopment or absolute muscle aplasia. Perhaps an acquired disease, in most cases due to damage to the diaphragm-feeding nervous system. There is a possibility of an absolute course of the process in which the dome is completely hit and moved. More often this is observed on the left. An alternative is a limited pathological process in which one of the sections of the diaphragm is thinned. More often this is observed on the right in the anteromedial zone.
In the case of relaxation, the lung from the affected area is compressed, the mediastinum is displaced in the opposite direction, gastric inversion or a similar pathology of the intestinal tract in the bend near the spleen is possible.
Relaxation to the right in a limited area is not symptomatic. If the process proceeds on the left, the symptomatology is similar to a hernia, but there is no risk of pinching, since there is no hernia gate. For the diagnosis, the displacement of the internal organs is studied, the condition of the lungs and the structures of the mediastinum are evaluated. Instrumental diagnostic methods - CT, X-ray examination.