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Diaphragm hernia: definition, symptoms, treatment

by Josephine Andrews
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The diaphragmatic hernia (hiatus hernia) occurs when there is a defect or weakness in the diaphragm (diaphragm). As a result, parts of the stomach or abdominal contents of different sizes pass into the chest cavity and lead to swallowing difficulties and upper abdominal pain. Depending on the type of diaphragmatic hernia, an operation is unavoidable, but not necessary in most cases. Find out everything you need to know about the diaphragmatic hernia here.

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

K44

quick overview

  • Symptoms: The symptoms depend on the type of diaphragmatic hernia and do not occur in all cases.
  • Treatment: The axial hernia usually does not need to be operated on. However, surgery should always be considered for the remaining hiatal hernias.
  • Causes and risk factors: A diaphragmatic hernia is either congenital or develops over the course of life. Risk factors for acquired diaphragmatic hernia include obesity and age.
  • Diagnosis: A diaphragmatic hernia can be diagnosed by X -rays , gastroscopy or magnetic resonance imaging (MRI), among other things.
  • Course of the disease and prognosis: The prognosis depends on the type of diaphragmatic hernia and the possible complications. It is usually a sliding hernia with a good prognosis.
  • Prevention: In order to reduce the risk of a diaphragmatic hernia, it is advisable to reduce obesity and avoid lack of exercise, among other things.

What is a diaphragmatic hernia?

In the case of a diaphragmatic hernia, medically known as a hiatus hernia, parts of the abdominal organs move through a hole in the diaphragm ( diaphragm ) into the chest cavity (thorax).

The dome-shaped diaphragm is made up of muscle and tendon tissue. It separates the thoracic from the abdominal cavity. It is also considered the most important respiratory muscle. It has three large openings: in front of the spine is what is known as the aortic slit, through which the main artery (aorta) and a large lymphatic vessel pass.

The aorta runs behind the abdomen and its organs. The inferior vena cava runs through the second, larger opening – it is firmly attached to the surrounding tendon tissue of the diaphragm.

The gullet (oesophagus) passes through the esophageal hiatus, the third large hole, where it opens into the stomach just below the diaphragm. The esophagus opening forms a direct connection between the chest and abdomen. Since the muscle tissue is comparatively loose at this point, a diaphragmatic hernia occurs here in particular.

Hiatal hernias are divided according to the origin and location of the parts that protrude into the chest cavity.

Type I hernia = axial hiatal hernia

The entrance to the stomach (cardia), where the esophagus meets the stomach, moves vertically upwards (more precisely along the longitudinal axis of the esophagus) through the opening. It then lies above the diaphragm. This diaphragmatic hernia often affects the entire upper part of the stomach, the gastric fundus.

Type II hernia = paraesophageal hiatal hernia

A portion of the stomach of varying size passes into the chest cavity next to the esophagus. In contrast to type I hernias, however, the entrance to the stomach remains below the diaphragm.

Type III hernia This diaphragmatic hernia is a hybrid of type I and II. It usually begins with an axial hiatal hernia. Over time, more and more sections of the stomach are shifting to the sides of the esophagus and into the chest cavity. The extreme form of this hiatal hernia is the so-called “upside-down stomach”: The stomach lies completely in the chest.
Type IV hernia This is a very large diaphragmatic hernia in which other abdominal organs such as the spleen or large intestine protrude into the chest cavity.

Extrahiatal diaphragmatic hernias

The commonly used term diaphragmatic hernia usually means organ displacement through the esophagus slit (hiatus oesophageus), therefore also called hiatal hernia.

There are also diaphragmatic hernias, in which abdominal organs protrude through other openings in the diaphragm. Experts summarize these under the term extrahiatal (i.e. outside of the esophagus slit) diaphragmatic hernias.

For example, there is a hole (Morgagni) at the connection point to the sternum, through which intestinal loops preferably move (Morgagni hernia, parasternal hernia). And a triangular gap in the back of the muscular diaphragm (Bochdalek’s gap) may also cause a hernia.

frequency

The diaphragmatic hernia through the esophageal slit is by far the most common form. These include axial hernias in about 90 percent of cases. On the other hand, fractures on the side of the esophagus, the paraesophageal hernias, very rarely occur alone. They are usually found in mixed forms (type III hernias).

Diaphragmatic hernias are more common in older people. If the hernia occurs due to a maldeveloped diaphragm, it is the congenital form. Doctors find a diaphragm defect in about 2.8 out of 10,000 births.

The diaphragm defect occurs in the eighth to tenth week of pregnancy. How exactly this developmental disorder occurs has not yet been finally clarified.

According to federal health reports, around 10,000 diaphragmatic hernias were diagnosed in German hospitals in 2012. Women were affected about twice as often as men. Congenital diaphragmatic hernias were found in 237 newborns in the same year.

How do you recognize a diaphragmatic hernia?

Whether you have symptoms of a diaphragmatic hernia usually depends on the type and extent of the hernia in question.

Axial hiatal hernia

Type I diaphragmatic hernias usually have no symptoms. Patients often report heartburn and pain behind the breastbone or in the upper abdomen. People with a diaphragmatic hernia may also notice a chronic cough.

However, it is less about diaphragmatic hernia complaints; rather, the symptoms are due to an accompanying reflux disease.

The contents of the stomach, especially the acidic gastric juice, flow into the esophagus. Normally, a closing mechanism prevents this backflow: Muscles at the entrance to the stomach (lower esophageal sphincter) tighten and thus protect the esophagus from stomach acid. In addition, the esophagus opens very steeply into the stomach. This circumstance makes reflux even more difficult.

The healthy diaphragm supports this process, which is why the risk of reflux increases if the diaphragm ruptures. Eventually, the upper end of the diaphragmatic hernia narrows and a so-called Schatzki ring develops. As a result, patients suffer from swallowing disorders or steakhouse syndrome: a piece of meat gets stuck and blocks the esophagus.

In some cases, cramp-like pain in the upper abdomen occurs when the diaphragm ruptures. These occur when the hernial sac is pinched. If the diaphragmatic opening presses too hard on the protruding section of the stomach, the stomach wall may be damaged. Doctors speak of the Cameron ulcer.

Paraesophageal hiatal hernia

At the beginning of a type II diaphragmatic hernia, there are usually no symptoms. As the disease progresses, patients find it difficult to swallow.

In some people, stomach contents flow back up into the esophagus. Especially after eating, patients often feel an increased feeling of pressure in the heart area and circulatory problems.

If the hernial sac twists, its blood supply is disrupted and the sections of the stomach it contains may die. Doctors speak of an incarceration that is life-threatening.

As with an axial diaphragmatic hernia, the tissue of the stomach wall may be damaged. The resulting defects may bleed unnoticed.

Approximately one third of all type II hernias therefore only become apparent as a result of chronic anemia. Doctors find the remaining two-thirds by accident or by swallowing difficulties. If a hiatal hernia causes severe symptoms, the hernial sac is usually very large. In extreme cases, the entire stomach moves into the chest cavity.

More diaphragmatic hernias

The symptoms of extrahiatal diaphragmatic hernias are similar. Some patients have no symptoms, while others have more complicated diaphragmatic hernias. Because as with hiatal hernias, the contents of the hernial sac – intestinal loops or other abdominal organs – die off and toxins are released that are life-threatening for the body.

Particular caution is required in newborns. A diaphragmatic hernia is almost always life-threatening for them. Because the parts of the abdomen that have passed over displace the heart and lungs in the still small chest.

Diaphragm hernia: how can it be treated?

A diaphragmatic hernia does not always require treatment. The axial hiatal hernia is only operated on when symptoms such as chronic reflux disease occur.

The backflow of gastric juice inflames the esophagus and attacks the mucous membrane. This may result in mucosal damage and bleeding.

If the reflux disease persists for a longer period of time, the risk of esophageal cancer is also significantly increased. If the mucous membrane has been damaged by a diaphragmatic hernia, a surgical intervention should also be considered.

In order to avoid possible problems caused by backflowing gastric acid, the doctor also prescribes appropriate medication. They either reduce the amount of acid (proton pump inhibitors, histamine receptor blockers) or balance the acidity (antacids).

diaphragmatic hernia surgery

All other hiatal hernias are treated surgically by specialists. A paraesophageal hernia is a complicated disease that is also operated on in symptom-free patients. This serves to prevent possible late effects of the diaphragmatic hernia.

Because even if the symptoms of a diaphragmatic hernia may not appear until late, the hernial sacs often increase in size as the disease progresses.

In the case of complications such as impaired chyme transport, torsion of the stomach or a trapped hernia content, which may die off quickly as a result, the doctors operate as quickly as possible.

The diaphragmatic hernia that has penetrated the thoracic cavity is properly relocated back into the abdominal cavity. The hernia gap is then narrowed and stabilized (hiatoplasty). In addition, the gastric fundus, i.e. the dome-shaped upper bulge of the stomach, is sewn to the left underside of the diaphragm.

At the end of the diaphragmatic hernia operation, the surgeons attach part of the stomach either to the anterior abdominal wall or to another part of the diaphragm (gastropexy).

If the aim of the diaphragmatic hernia operation is only to correct the reflux disease, the so-called fundoplication according to Nissen is carried out. The surgeon wraps the fundus of the stomach around the esophagus and sutures the resulting cuff. This increases the pressure on the lower esophageal sphincter at the mouth of the stomach and gastric juice hardly flows upwards.

plastic nets

If the diaphragmatic defect is too large, doctors usually use plastic mesh to close the hernia gap. Caution should be exercised, especially in the case of congenital defects of the diaphragm.

The newborns need intensive medical care because the diaphragmatic hernia hardly allows them to breathe properly. Artificial respiration is then necessary. Only when the circulation and breathing are stable is the operation performed.

How does a diaphragmatic hernia occur?

In the case of a diaphragmatic hernia, a distinction is made between congenital and acquired forms. The latter has various causes and dimensions. Congenital diaphragmatic hernias, on the other hand, usually result from an abnormal development of the diaphragm.

Developmental disorders during the embryonic period

The diaphragm develops in two phases. First, a wall of simple connective tissue separates the thoracic from the abdominal cavity. Since the diaphragm consists of two parts (transversal septum and pleuroperitoneal membrane), there is initially a gap. This closes faster on the right than on the left.

In the second phase, the muscle fibers grow in. If a disturbance occurs during this period (fourth to twelfth week of pregnancy), a defect develops in the diaphragm.

Abdominal parts may shift into the chest through these gaps. Since organ covers, such as the peritoneum, are not yet formed at the beginning, the organs are exposed in the chest cavity.

Approximately 70 to 80 percent of all paraesophageal hiatal hernias are due to a congenital diaphragmatic defect. In the case of developmental disorders of the diaphragm, there is often a large opening through which the esophagus and aorta run together (hiatus communis).

Body position risk factor

The axial diaphragmatic hernia is also called sliding hernia. The ruptured abdominal contents slip back and re-enter the chest cavity. It slides back and forth between the chest and abdomen.

The stomach sections shift mainly when lying down or when the upper body is lower than the abdomen. If those affected stand upright, the shifted parts return to the abdomen following gravity.

Risk factor pressing

The likelihood of a diaphragmatic hernia is increased when people tighten their abdominal muscles. This “squeezing” increases the pressure in the abdomen. As a result, the stomach, which lies directly below the diaphragm, is pushed up by the weak or defective diaphragm. The risk also increases with forced exhalation, abdominal pressure and bowel movements.

Risk factors obesity and pregnancy

Similar to pushing, obesity (obesity) and pregnancy also increase the risk of a diaphragmatic hernia. An excessive amount of fatty tissue in the abdomen (peritoneal fat ) increases the pressure on the organs, especially when lying down.

As a result, they are displaced – especially upwards. During pregnancy, the child growing in the uterus requires more and more space in the abdominal cavity. The organs are pushed upwards. As a rule, such a diaphragmatic hernia recedes without any problems after birth .

risk factor age

Age appears to play a role in the development of diaphragmatic hernias. For example, sliding hernias can be detected in 50 percent of people older than 50 years.

Specialists assume that the connective tissue of the diaphragm is weakening and the esophageal slit is widening (pulling out). In addition, the ligaments between the stomach and diaphragm loosen where the esophagus meets the stomach.

As a result, the esophagus opens flatter into the stomach than it normally does. Doctors speak of a cardiofundal malformation or an open esophagus-stomach junction, which increases the risk of diaphragmatic hernia.

diagnosis and examination

Many hiatal hernias are discovered incidentally when the doctor does an X-ray or a follow-up gastroscopy. As a rule, this is done by a specialist in gastroenterology in the field of internal medicine, sometimes also by a lung specialist (pulmonologist).

Some patients with diaphragmatic hernias suffer from heartburn and go to their family doctor with such symptoms.

Medical history (anamnesis) and physical examination

If a patient with diaphragmatic hernia complaints consults a doctor, the doctor will ask him specifically about the symptoms that are occurring: how the complaints are expressed, since when and in what situations they have been occurring and how they may be getting worse.

In this context, previously known diaphragmatic hernias in the patient are particularly important. Since traumatic events such as an operation or an accident also damage the diaphragm, such information plays a crucial role.

In about 30 percent of patients, doctors find gallstone disease (cholelithiasis) and protrusions of the intestinal wall (diverticulosis) in addition to the diaphragmatic hernia. Medically, these three frequently occurring diseases are called Saint-Trias.

The doctor therefore also goes into the previous medical history. If bowel loops are displaced in the diaphragmatic hernia, the doctor may hear bowel sounds over the chest with a stethoscope.

Further investigations

For the exact classification and planning of a diaphragmatic hernia treatment, the doctor carries out further examinations.

method Explanation
roentgen A chest X-ray often shows an air bubble behind the heart and over the diaphragm in the case of a diaphragmatic hernia. This finding points primarily to a hiatus hernia type II and III.
pap swallow, contrast agent In this examination, the patient swallows a contrast medium. The doctor then takes an X-ray. The pulp, largely opaque to X-rays, is clearly visible and shows possible narrowings which it does not pass. Or it appears above the diaphragm in the chest cavity in the area of ​​the diaphragmatic hernia.
gastroscopy

(Oesophago-Gastro-Duodenoscopy, EGD)

A diaphragmatic hernia is sometimes accidentally discovered during an examination of the esophagus, stomach and duodenum. The axial hiatal hernia is then revealed by a constriction below the actual entrance to the stomach or the lower esophageal sphincter. This method can also be used to diagnose a significant narrowing, the Schatzki ring. A paraesophageal diaphragmatic hernia is difficult to distinguish from the mixed form. If there is an accompanying inflammation of the esophagus caused by gastric juice (reflux esophagitis), an inflammation of the stomach (gastritis) or tissue damage (ulcer), it is important to discover this or, if it does not exist, to rule it out.
esophageal pressure measurement The so-called esophageal manometry determines the pressure in the esophagus and thus provides indications of possible movement disorders caused by a diaphragmatic hernia.
Magnetic resonance imaging (MRI) and computed tomography (CT) These more detailed imaging tests are especially useful for diaphragmatic hernias that don’t go through the esophageal slit. The detailed slice representation also plays a major role in planning treatment, in this case an operation.
Ultrasound (of the fetus) In the case of a congenital diaphragmatic hernia, a fine ultrasound in the unborn child shows relatively early whether an intervention is necessary. The doctor measures the ratio between the lung area and head circumference and thus estimates the extent of the diaphragmatic hernia.

Course of the disease and prognosis

In about 80 to 90 percent of sliding hernias no therapy is necessary. And after an operation, around 90 percent of patients with a diaphragmatic hernia are symptom-free.

In newborns, the prognosis depends mainly on the extent to which the lung volume is restricted. Since the diaphragmatic hernia already exists before birth, the lung on the affected side is usually underdeveloped. In severe cases, the mortality rate is about 40 to 50 percent.

complications

A diaphragmatic hernia progresses less favorably if complications arise. If the stomach or the contents of the hernial sac twist, for example, their blood supply is cut off. As a result, the tissue becomes inflamed and dies. The toxins released as a result are distributed in the body and cause severe damage (sepsis).

If large parts of the abdominal organs are displaced due to the diaphragmatic hernia, the lungs and heart are constricted in the chest. A diaphragmatic hernia can cause circulatory problems and breathing problems (shortness of breath). In these cases, the operation is carried out quickly and the person concerned is cared for in an intensive care unit. In addition, bleeding from tissue damage causes chronic anemia.

Because most hernias are harmless and symptom-free sliding hernias, a diaphragmatic hernia is usually uncomplicated and has a good prognosis.

Prevent

Obesity and lack of exercise increase the risk of hiatal hernia. It is therefore advisable to change your diet and lifestyle in the event of a diaphragmatic hernia and to achieve weight loss, i.e. to exercise more often and eat smaller meals.

It is also advisable not to eat anything right before going to bed. Especially in the case of a known sliding hernia, a slightly elevated upper body position at night prevents abdominal organs from sliding up into the chest cavity again. This also reduces heartburn and reduces the risk of reflux disease and its consequences.

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