The diaphragm is a powerful organ, which consists mainly of muscle that separates the chest cavity from the abdominal cavity and participates in the act of respiration. In the Central part of the diaphragm there is a natural hole, through which pass the large blood vessels (aorta) and the organs (esophagus), it is in these places very often formed of a hernia.
The content of the article
Hernia hiatal Hernia hiatal occurs because of the movement of the upper parts of the stomach, lower esophagus or intestines into the chest cavity. In the same way can be moved and other organs such as the spleen, the left lobe of the liver, the site of the greater omentum.
A little anatomy
The diaphragm is attached to the inner surfaces of the ribs, spine and sternum. Has two domes, a Central part which consists of strong connective tissue. Directly above the domes of the diaphragm is placed the heart and lungs, and under them – the abdominal part of the esophagus, stomach, and liver.
Schematic representation of the stomach is the Esophagus has the form of a tube and connects the throat with the stomach, its length is about 25 cm. a Small part of the esophagus lies in the neck, he then descends into the thorax, lying between the lungs, and then penetrated through the esophageal opening of the diaphragm, connects with the stomach. Abdominal length of esophagus is about 3-4 cm, moving gradually in the cardiac part of the stomach. In this place formed his angle, which is of great importance when choosing the method of surgical treatment of hernia hiatal. The stomach is divided into the following parts:
- the bottom of the stomach;
- the body of the stomach;
- pyloric Department;
- the pylorus (the sphincter that separates the stomach from the duodenum 12).
The causes of hernia
In children hernia esophageal Department of the diaphragm often occurs at short esophagus congenital anomalies of development in which the cardiac section of the stomach is in the chest cavity. Upon detection of this disease is performed surgery.
Hernia hiatal develop and due to other reasons, among which are:
- age-related weakening of the ligaments of the stomach and esophagus;
- diseases associated with congenital malformation of the ligaments (Marfan syndrome, varicose veins of the lower extremities, diverticulosis of the sigmoid colon);
- inflammatory diseases of the gastrointestinal tract (stomach ulcer and 12 duodenal ulcer, chronic gastroduodenitis, calculous cholecystitis, pancreatitis);
- diseases of the esophagus (esophagitis, diverticula, and burns of the esophagus, Barret’s esophagus, strictures, varicose veins of the esophagus);
- traumatic injury of the diaphragm and esophagus;
- prolonged increased pressure in the abdominal cavity (hard physical labor, weightlifting, continuous vomiting, prolonged constipation, flatulence, obesity, ascites, tumors).
Under the influence of the above factors esophageal opening of the diaphragm expands, resulting in stretched ligaments, and the abdominal organs move into the chest cavity.
There are 4 types of hernias hiatal:
- Sliding (axial) hernia occurs when the abdominal part of the esophagus and the fundus of the stomach freely penetrate into the chest cavity. However, his angle (formed between the esophagus and the gastric fundus) from 20 gradually comes to 180 degrees, thus there is failure of the lower esophageal sphincter. This type of hernia is found in 85-90% of cases, almost never prejudiced.
- Okoloplodna (paraesophageal) hernia is less common in 15-10% of cases. In this hernia the esophagus is fixed at its typical location, and the bottom of the stomach or other organs protrude freely through the esophageal opening into the cavity of the chest. This type of diaphragmatic hernias have a tendency to infringement, which requires immediate surgical intervention.
- Combined hernia combine the properties of two previous types of hernias.
- The acquired short esophagus is formed with injuries of the abdomen and the chest or inflammatory diseases that affect the esophagus, which causes shortening of its length. In this case, the stomach is drawn into the mediastinum (the space between the two lungs). This requires a plastic operation on the esophagus.
Classification of hernias hiatal
Share the three stages of hernia hiatal:
Stage I. Abdominal part of the esophagus immersed in the mediastinum, and the bottom of the stomach is closely touches the diaphragm.
Stage II. Cardiac section of the stomach and fundus of the stomach is placed in the esophageal opening of the diaphragm.
Stage III. Located in the mediastinum of the abdominal esophagus, cardiac part, fundus and body of the stomach.
Generally considered to be that hernia hiatal there are asymptomatic for decades and can be discovered accidentally during routine medical examination.
Among the main abdominal symptoms are:
- heartburn. Very common and has a pronounced, patients concerned about the feeling a burning sensation behind the breastbone. It happens more after eating, lying down, when bending (tying Shoe laces, work at home), during exercise. Heartburn is an early sign of gastroesophageal disease.
- pain behind the breastbone and in the epigastrium. They are associated with the compression of the organs that protrude through the esophageal opening. The pain can be unbearable when the hernia incarceration. They can also masquerade as heart disease (angina, myocardial infarction).
- burp. This symptom is accompanied by feeling of bitterness and acid in his mouth.
- dysphagia. Is accompanied by a disturbance of movement of food through the esophagus, occurs after a hasty meal, copious drinking, consumption of spicy and fried foods.
- hiccup, periodic vomiting.
- pain in region of heart;
- shortness of breath;
- cyanosis of the skin after eating.
Having had 3 or more of these symptoms, the patient should consult a doctor and take the full course examination to confirm or refute the presence of a hernia hiatal.
Among the most effective methods of examination that help accurately diagnose a hernia hiatal, are the following:
Fluoroscopy and radiography. It’s old, but reliable method which shows the topography of the inner surface of the digestive tract. The patient must drink a barium contrast mixture, to make a series of x-ray images in different projections, where it is possible to detect the presence of protrusions in the esophageal opening of the diaphragm and to determine the stage of development of the disease. The standard pictures of the chest you can see a gas bubble of the stomach, which is located in the chest cavity, displacement of heart and mediastinum to the unaffected side.
Paraesophageal strangulated hernia hiatal in direct and lateral projections.
Fibroezofagogastroduodenoscopy. With the help of the fiberscope is possible to visually examine the lining of the esophagus and stomach for signs of erosions, ulcers, strictures (scar narrowing of the body), diverticula (a separate pocket of the esophagus) and anatomical deformations.
UZD. Ultrasound examination can detect a defect of the diaphragm, the shifting boundaries of the heart and vessels of the mediastinum.
SKT. Computed tomography is the “gold standard” in the diagnosis of hernia hiatal. Using this method it is possible, with sufficient clarity to detect the size of the defect, its contents, blood supply and the ratio of abdominal and pleural cavities.
Esophageal manometry. This method allows to estimate functional capabilities of the sphincter of the esophagus and cardia of the stomach, the efficacy of the treatment.
As a pre-operative hernia complications hiatal speakers:
Reflux esophagitis is a complication and one of the first symptoms of this type of hernia
- infringement. Most often the infringement is exposed to the stomach that can provoke it purulent inflammation and death. Patients complain of severe pain in the upper abdomen, hiccups, heartburn, vomiting, chest pain and General weakness. In such cases it is necessary to immediately perform the operation, release the stomach from injury and to observe patients in the future.
- reflux esophagitis. This is often the first symptom of a hernia, the appearance of which the patient comes to the doctor. In this case, patient feels heartburn after a meal, exercise, and in a horizontal position.
- erosion, ulcers of the esophagus and stomach. When the stomach and esophagus are in the hernial SAC, these bodies cease to function normally, are weakened and the sphincter acidic contents of the stomach begins to flow into the esophagus. This leads to the appearance of erosions and then ulcers of the mucous membrane, which bring pain, a feeling of acid in the mouth and heartburn.
- gastro-intestinal bleeding. Is often hidden and occurs on the background of ulcers and erosions of the stomach. Manifested by vomiting with blood or coffee ground, General weakness, paleness of the skin, sometimes loss of consciousness. This complication can be docked with conservative treatment.
Treatment of hernia hiatal diafragmalna without surgery
To begin treatment of hernia hiatal need with conservative methods, especially at the 1-2 stages.
You must adhere to dietary diet, namely:
- eating 5-6 times a day in small portions;
- after eating for 1 hours do not lie on the bed;
- dinner should be 2-3 hours before bedtime;
- you can eat pureed fruits and vegetables, boiled meat and fish, cereals, jellies, vegetable soups;
- before eating drink 1 tablespoon sunflower or olive oil;
- forbidden to take of fried, fatty, salty food;
- prohibited Smoking.
When it begins to disturb heartburn, belching, abdominal pain, you can resort to medical treatment. At night it is recommended to take drugs that lower the acidity in the stomach (omeprazole, esomeprazole), 2-gistaminoblokatora (ranitidine, famotidine) antacids (aluminium hydroxide). Also effective tools that stimulate the motility of the stomach and esophagus, namely metoclopramide, domperidone.
A sliding hernia is necessary to operate only when severe clinical manifestations of reflux esophagitis, which are not amenable to conservative therapy. Used as access from the abdomen and thorax.
The hernia the Nissen is currently widely used operations that are capable of eliminating reflux (reflux of stomach contents into the esophagus). One such operation is the Nissen fundoplication, during which narrows the esophageal opening with the nodal sutures. During the operation part of the stomach envelop the abdominal esophagus, exacerbating the angle of his, which prevents the reflux of acid content. Partially narrows the esophageal opening, making impossible the protrusion of the organs in the thoracic cavity. This type of surgery can be performed by open method and laparoscopy.
Okolovodnye hernias are characterized by a strong fixation of the cardiac part of the stomach to the diaphragm, while the bottom of the stomach or loops of bowel to enter the chest cavity through an enlarged esophageal opening. This kind of hernia is rare but often leads to complications — infringement or bleeding. Therefore, these hernias surgery are significantly more likely than moving. The basic principle followed by surgeons, to be reduced to reduce the esophageal opening and fixation of the gastric fundus to the diaphragm.
The postoperative period
When not complicated hernias this period covers a total of 7-8 days.
In the first days after surgery the patient should the probe into the stomach to remove gastric contents. The patient is infusion therapy (the injection of saline solutions into the vein), it is forbidden to drink and especially eat.
On the second day through a tube introduced saline or glucose to stimulate the bowel. The patient can sit, stand and move slowly.
On the third day allowed to drink water in small quantities and only in a sitting position, the probe from the stomach is removed. With 4 days allowed to eat jelly, vegetable soup, baked apples, meat balls, dispensing meals 5-6 times.
In the late postoperative period you need to stick to a diet, stop Smoking and coffee can limit heavy exercise.