Diaphragm hernia: symptoms, causes, treatment methods, prognoses

Diaphragmatic hernia is a fairly common pathology of a chronic nature, which affects about five percent of the adult population. It is diagnosed most often in women after 60 years, as well as in pregnant women. This article will discuss the symptoms and treatment of a hernia of the food opening of the diaphragm, as well as the causes of its formation.

general information

The esophagus is located inside the chest cavity, and the stomach is in the abdominal cavity. Their border falls on the esophageal opening of the diaphragmatic muscle, where the valve (sphincter) is located. In the esophagus, the environment is neutral and its main function is the transit of food. The stomach is acidic, and its main purpose is digestion. Part of the stomach slips into the chest cavity when a hernia of the diaphragm of the esophagus occurs.

Symptoms of this phenomenon are very unpleasant and are associated with the reflux of acid from the stomach into the esophagus. This condition is usually accompanied by an inflammatory process in the mucous membrane of the esophagus, i.e., esophagitis.

Causes of hernia

There are several factors that contribute to its formation:

• High pressure in the peritoneum. The provocateurs of this condition are cough, overweight, prolonged flatulence or constipation. In rare cases, the formation of a hernia is associated with obstructive pulmonary disease, which results in the expansion of the lung tissue, i.e., emphysema. All of the above phenomena provoke an increase in abdominal pressure.
• Weak ligamentous apparatus holding the esophagus in the diaphragmatic opening. A change in the elasticity of the ligaments and the inability to perform their functions of keeping the stomach and esophagus in the right position can be against the background of pathologies associated with connective tissue insufficiency. In some cases, such changes occur with age, and the individual manifests symptoms of a hernia of the esophageal diaphragm.
• Violation of gastrointestinal motility, which is mainly caused by the following anomalies: gastritis with high acidity, gallstone disease, gastric ulcer.

Types of hiatal hernia

By the mechanism of education, the following types are distinguished:

• Moving, or it is also called axial, axial. In this case, the stomach, or rather its fundus and cardiac section, as well as the part of the esophagus located under the diaphragm, moves through the abnormally expanded esophageal opening of the diaphragm along its axis into the chest cavity and then returns. This phenomenon is often observed when changing the position of the individual. This type of diaphragm hernia is most often diagnosed.
• Paraesophageal (congenital) - the stomach or part of it moves relative to the esophagus, which remains motionless, into the chest cavity. This occurs at the stage of embryonic development.
• Mixed - combines the two previous options.
• A large defect in the diaphragm, in which prolapse of several organs of the abdominal cavity is observed.

Sliding hernias may be stationary, i.e., incapable of being repaired when the individual moves to a vertical position. This phenomenon is characteristic of large hernias.

The following degrees of axial hernia are distinguished, depending on the displaced area:

• the first is the esophagus;
• the second is cardiac;
• the third is cardiofundal;
• the fourth is gigantic.

Paraesophageal hernias are:

• Fundamental
• antral.

Symptoms of a hernia of the diaphragm of the esophagus

The clinic of a hernia of the esophagus is associated with the ingress of acid contents from the stomach into it and the appearance in the chest cavity of the so-called organ in the form of a section of the cardia. This phenomenon is accompanied by the following symptoms:

• Chest pain, which is pressing and burning in character. It is easy to confuse it with an attack of angina pectoris.
• A feeling of lack of air and even suffocation.
• Hoarse voice.
• Fullness behind the sternum and a feeling of discomfort, which is provoked by lifting the stomach up.
• A cough that manifests itself mainly when the individual is lying.
• A painful and long heartburn that appears both after eating and on an empty stomach. Its provocateurs are hot and spicy foods.
• Belching, which is aggravated by tilting the body. In some cases, it comes to the contents of the stomach entering the oral cavity.

Many symptoms of a hernia of the diaphragm are nonspecific, for example, coughing or chest pain, which makes timely diagnosis difficult and mask the disease. A pressing pain behind the sternum requires the exclusion of such a pathological condition as an attack of angina pectoris. Therefore, the patient is always prescribed an ECG. In most cases, hoarseness and cough are present with a hernia of the esophagus. The reason for this phenomenon lies in the casting of acid into the larynx and pharynx. As a result, signs appear in the form of a cough and a dry, obsessive cough, similar to diseases such as laryngitis, pharyngitis or tracheitis. In addition, the symptoms of a hernia of the esophageal diaphragm are similar to esophagitis, gastric ulcer.

Causes of the formation of a sliding hernia of the esophagus

Causes of the disease are congenital (natural) and acquired factors. Of the latter, it should be distinguished:

• increased abdominal pressure;
• age-related changes in the diaphragm;
• cholecystitis, ulcerative lesions and severe contractions of the esophagus;
• relaxation or trauma to the nerve tissue of the diaphragm.

Congenital factors include:

• untimely fusion of the diaphragm;
• insufficiently rapid lowering of the stomach in the embryonic period;
• underdevelopment of the muscles of the diaphragmatic legs and an enlarged esophagus.

In addition, obesity, pregnancy, stomach diseases that increase pressure in the peritoneum can provoke symptoms of a hernia of the diaphragm.

Signs of a sliding esophageal hernia

Pain in the stomach and heartburn are the most characteristic symptoms of the disease. With an axial hernia, the upper part of the stomach moves through the diaphragmatic opening into the chest cavity, and then returns to its original position. In practice, the signs are mild and a hernia is detected quite by accident, for example, during radiography. The main symptoms of a sliding hiatal hernia are as follows:

• When the body is tilted, a burning pain appears in the epigastric region, as well as behind the sternum.
• The ingestion of food in the oral cavity and esophagus in the absence of vomiting.
• Severe heartburn, especially after eating and when the individual takes a horizontal position.
• Due to the penetration of acidic contents from the stomach into the respiratory tract, frequent ailments of the upper respiratory tract are recorded in the form of bronchitis, tracheitis.
• Reflex violation of swallowing, even during the period of drinking liquid food. Further, with inflammation of the mucous membrane of the esophagus, a food lump passes through it with great difficulty.

In rare cases, there is an increase in pressure and salivation.

Physical exercise

For the most part, all symptoms of a diaphragm hernia increase due to physical activity, and especially with weight lifting, as a result of which pressure on the diaphragm increases from below. The loads after eating food are recognized as the most dangerous, since during this period the stomach also exerts pressure on the diaphragm. You can give an impetus to the appearance of signs of a hernia within thirty minutes after eating by doing the following:

• sharply tilt the body forward;
• take a lying position.

This is due to the fact that the above processes are accompanied by the transition of a part of an overflowing stomach into the chest cavity. At the first symptoms of a hernia of the diaphragm, you should consult a doctor for examination and subsequent treatment.

Diagnostics

Diagnosis is carried out using instrumental methods. Esophagogastroduodenoscopy helps to identify the cardiac section of the stomach. Radiography is done in several stages:

• The first is the abdominal organs. Identify the location of the stomach, diaphragm and shadow of the esophagus.
• The second is the esophagus and stomach using a contrast medium. Check the rate of emptying of the stomach and analyze the passage through the digestive tube of contrast.
• Third - take pictures when the individual is in a horizontal position.
• Fourth - in the vertical position of the patient is examined for the presence or absence of contrast medium in the esophagus, and also the location of the stomach bladder is revealed.

Esophageal manometry is used to evaluate the contractile activity of the esophagus.

The following methods are used to diagnose a sliding hernia:

• X-ray
• esophageal pH;
• endoscopy;
• gastroscopy;
• sounding of the esophagus;
• study of the esophageal-gastric transition.

It is impossible to see a hernia of the diaphragm using FGDS and ultrasound. In rare cases, it is detected by doing an MRI.

Uncomplicated hernia treatments

For the treatment of such hernias, conservative therapy is used, including:

• Dietary nutrition. Treatment of symptoms of a hernia of the diaphragm of the esophagus involves taking semi-liquid food. Moreover, it is forbidden to eat at bedtime, as well as to take a horizontal position after eating. Boiled, stewed, steamed dishes prepared from dietary varieties of meat and fish, cereals, vegetables and fruits make up the basis of nutrition. One serving should not be more than 250 grams. Food that stimulates mucosal irritation and the production of digestive juice, i.e. smoked, fried, spicy and fatty foods, should be excluded from the diet.
• Changing the rhythm of life. In the treatment of symptoms of a hernia of the esophageal opening of the diaphragm, an individual should completely eliminate smoking and drinking alcohol-containing drinks, as well as reduce physical activity. All sports activities that increase pressure in the peritoneum are contraindicated. A full day and night rest is required.
• Pharmacotherapy. The following groups of medicines are recommended: reducing acidity - “Maalox”, “Gastal”; painkillers and antispasmodics - “No-shpa”; suppressing the formation of hydrochloric acid - "Omeprazole"; eliminating heartburn and burping - "Motilium".

If there is a small hiatal hernia, the treatment of symptoms consists of several stages:

• fractional nutrition;
• medical diet;
• prevention and treatment of constipation;
• the use of drugs that reduce the production of gastric secretion.

Drug therapy for diaphragm hernia

In this case, doctors recommend medicines that restore the motility of the stomach and esophagus, lower secretory activity, antihistamines, as well as antacids, which stop the symptoms of a hernia of the esophageal diaphragm. Treatment begins immediately after diagnosis. Commonly prescribed drugs:

• Omez.
• Pantoprazole.
• "Famotidine."
• "Ranitidine."
• Gastal.
• Almagel.
• "Maalox."
• "Metoclopramide."
• Motilium.

The dosage and frequency of administration is selected by the attending doctor.

Surgical methods for removing a diaphragm hernia

Surgical treatment of symptoms of a hernia of the esophageal opening of the diaphragm is the most effective method in connection with the possibility of its infringement. Removal Methods:

• Transthoracic access in the seventh-eighth intercostal space is indicated for left-handed hernia of the diaphragm.
• Upper median laparotomy is used for parasternal hernias.
• When localized on the right side, the operation is performed through transthoracic access in the fourth intercostal space.

All surgical interventions include goals such as forming an antireflux barrier and removing hernial gates. Cavitary and laparoscopic methods are used. The latter method is the safest, has a short hospitalization. When identifying both indications and contraindications for surgical treatment of diaphragm hernia, symptoms and their severity, as well as the presence of concomitant diseases, are also taken into account. For example, an operation is not performed for cirrhosis of the liver, severe oncological pathology, heart problems, or decompensated diabetes mellitus. After surgery and following the doctor's recommendations during the rehabilitation period, most individuals report an improvement in quality of life.

This is primarily due to the disappearance of such regular symptoms of diaphragm hernia as belching and heartburn. In the future, the patient is obliged to comply with all the recommendations of the doctor, which include changing the lifestyle, proper diet, reducing physical activity and taking certain medications. The prognosis of the disease is favorable provided that it is detected in a timely manner, high-quality therapy and a certain diet are observed.

Diet food

To obtain good results, it is important to combine the treatment of symptoms of diaphragm hernia and a diet, adherence to which positively affects the patient's well-being. The diet should include:

• eggs
• dried bread;
• cottage cheese;
• cereals;
• sour cream;
• cheese;
• dairy products;
• pasta;
• boiled or steamed vegetables;
• low-fat fish and meat;
• baked potatoes;
• chicken and beef broth;
• persimmon;
• dried fruits;
• bananas
• berries (currants, strawberries and blueberries);
• honey;
• mineral water without gases.

Steamed food or stewed, baked. Salty, smoked, fatty, fried and coarse foods with the addition of various sauces, peppers, onions, garlic and seasonings are prohibited. Eat small meals at least six times a day. The fruits are peeled and ground on a fine grater. One teaspoon of honey per day will help deal with heartburn. Drinking a large amount of fluid per day (two to three liters), including stewed fruit, will help protect against constipation.

The following products should be discarded:

• acidic varieties of berries and fruits: oranges, cranberries, pomegranates, cherries, lemons, etc .;
• chocolate;
• juices;
• milk;
• strong tea;
• black bread and bran;
• coffee;
• carbonated and alcohol-containing drinks;
• drying cookies.

Solid meals are not recommended. The use of cabbage, legumes and fresh baked goods is desirable to limit. The herb of lemon balm and mint can cause an exacerbation of the hernia, as it helps to weaken the sphincter. Therefore, they should be rejected.

Complications of a hiatal hernia

In the first place among the consequences of this pathology is reflux esophagitis. It has several degrees of severity and is manifested by the following changes:

• catarrhal;
• ulcerative erosive.

As well as acquired shortening of the esophagus and / or inflammatory-cicatricial narrowing of the lumen. The following abnormal conditions are rare:

• esophageal perforation;
• esophageal-gastric or esophageal bleeding, acute and chronic;
• infringement is characteristic only for paraesophageal hernias;
• angina reflex;
• the introduction of the esophagus into the hernial part;
• and others.

Recommendations

Observance of the following tips will help reduce the risk of exacerbations and reduce the severity of symptoms of a hernia of the food opening of the diaphragm:

• With this disease, it is not recommended to take the following medications: Diclofenac, Acetylsalicylic acid, Nifedipine, Diltiazem, as they provoke relaxation of the sphincter and aggravate the symptoms of the disease.
• It is necessary to timely treat such pathological conditions as flatulence, cough, constipation. In addition, it is necessary to reduce excess body weight. The implementation of these recommendations will reduce intra-abdominal pressure, and, accordingly, the frequency of exacerbations of the underlying disease.
• After eating for about two hours, you should not take a reclining or lying position.
• Do not lift heavy things. During the period of remission, it is allowed to carry insignificant weight. However, this should be done one hour after or before meals.
• Shoes should be seated on a stool or chair using a footrest.
• Exclude any inclinations. To wash floors only with a mop.
• The bed for sleep should be with a raised headboard.

Preventive measures and treatment of symptoms of diaphragmatic hernia will reduce the risk of serious consequences and the likelihood of future surgery. The operation is indicated for bleeding and in the late stages of axial hernia.