Hernia of the esophageal opening of the diaphragm: symptoms, causes, degrees, treatment, diet, photo

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Hernias of the esophageal opening of the diaphragm( GVAP) are classified as fairly common pathologies, the risk of which increases in patients in proportion to their age.

Thus, in patients under the age of forty, they occur in 8% of cases, while in patients over seventy, their number increases to 70%, and women are more susceptible to them.

In almost half of patients, this pathology is characterized by complete asymptomatic leakage, and remains unrecognized. Patients may for years be under the supervision of a gastroenterologist and treat associated diseases( gastric ulcer, chronic gastritis, cholecystitis) with similar clinical symptoms.

Concept of the pathology of

In the international classification of diseases of hernia of the esophageal aperture of the diaphragm the code K44.9 is assigned.

Diaphragmatic hernia is accompanied by severe chest pains, arrhythmia, dysphagia( difficulty passing food through the esophagus), heartburn, regurgitation( eructation) and hiccups.

Classification of

Based on anatomical features, the hernia of the esophageal opening of the diaphragm is divided into:

• Sliding.
• . Paraseophageal.
• Mixed. In the pathologies of this type, the manifestations of two mechanisms are combined: paraeophagous and axial.

Sliding

Sliding hernia( also called axial or axial) of the esophageal opening of the diaphragm is characterized by free movement of the abdominal section of the esophagus( this is called a small( about two centimeters long - a piece of the esophageal tube located under the diaphragm), a cardia( annular sphincter located between the stomach andesophagus) and the bottom of the stomach into the thoracic cavity and the equally free return of these organs to the abdominal cavity.

The reason for such movements can be the usual change in the position of the body.

Axial

Axial hernia of the esophageal opening of the diaphragm is formed as a result of the weakening of the surrounding diaphragmatic muscles.

Without being fixed, they do not appear constantly, but only under the influence of certain factors. The most important are: the position of the body, the degree of fullness of the stomach and intra-abdominal pressure.

Weakened muscles of the diaphragm allow the lower part of the esophagus and parts of the stomach to slip freely into and out of the chest cavity. Hernias of the axial type are the most common pathologies.

The volume and level of elevation above the diaphragm of the displaced areas allows them to be divided into:

• Cardiac.
• Cardiofundal. Hernias of this type are characterized by free movement of the upper part of the stomach.
• Subtotal and total gastric. With these varieties of hernia above the level of the diaphragm, either a large part of the stomach or all of its body is found.

Cardial

In this type of pathology, only the cardiac sphincter that separates the esophagus from the stomach slips through the esophageal aperture of the diaphragm.

Of the total mass of axial hernias, 95% of cases are cardiac pathologies. The remaining 5% are distributed between cardiofundal, subtotal and total gastric hernia.

Parasophageal

Cases of paresisophageal hernia of the esophageal diaphragm are relatively rare.

Their radical difference from a sliding hernia consists in the fact that the large curvature of the stomach, its bottom, and part of the loops of the small or large intestine moves to the epithelial tracheoesophageal septum region at a fixed position of the cardiac valve: it remains under the diaphragm.

As a result of the movement, the above mentioned organs are disadvantaged. This often results in serious mechanical complications.

As a result of migration of the peritoneal sac, surrounding the stomach, the thoracic cage gradually moves into it first the fundus of the stomach and then its large curvature. During the ascent, the greater curvature is drawn upward, and the small curvature held by the cardiac valve continues to maintain its lower position.

Over time, the entire stomach( along with the tissues of the parietal pleura) can move to the chest cavity. Contrary to the movement of the stomach and a number of abdominal organs into the thoracic region, the fixation of the gastroesophageal junction continues to maintain a normal sub-diaphragmatic position.

In very rare cases, when there is a migration of the gastroesophageal passage into the chest cavity, there is evidence of a mixed hernia, often accompanied by a deficiency of cardiac pulp( cardia).

Fixed

Fixed hernia of the esophageal opening of the diaphragm is called a pathology in which the cardiac part of the stomach moves to the chest area and a constant( without slipping back) its stay in the zone of new localization.

This explains not the transitory, but the permanent nature of the clinical symptomatology that accompanies this pathology.

Fixed hernia is a rare, but much more dangerous( rather than an axial hernia) form of pathology, much more often leading to complications that require immediate assistance from a qualified specialist.

Infringement of a hernia, as a rule, requires the performance of a surgical operation.

Non-fixed

Non-fixed hernia of the esophageal opening of the diaphragm( also referred to as sliding or axial) is a chronic disease in which a free movement( migration) of the abdominal esophageal tube, lower esophageal pulp and stomach from the abdominal cavity to the thoracic cavity occurs through the above-mentioned aperture.

As a less complex disease than the above pathology, non-fixed hernia, however, requires equally serious and immediate therapy.

Causes of

The cases of hernia of the esophageal opening of the diaphragm are detected in 6% of the adult population, half of these cases occur in people older than fifty-five years old, in whose organism the age-related changes( atrophy, dystrophic processes and loss of elasticity) led to a significant weakening of the ligamentous retaineresophageal tube in the correct position.

Another category of persons susceptible to this disease are people with asthenic type of build or never engaged in sports.

The weakening of the ligamentous muscle and the formation of a hernia of the esophageal opening of the diaphragm can occur under the influence of:

1. Anatomical features of the body, formed during the fetal development of the fetus at the stage of the formation of muscle structures.
2. Concomitant diseases due to the weakness of connective tissue. To this group of ailments can be ranked: hemorrhoids, flat feet, intestinal diverticulosis, Marfan syndrome, varicose veins. In such patients, a hernia of the esophageal opening of the diaphragm is often accompanied by an umbilical, femoral and inguinal hernia and a preperitoneal lipoma( a hernia of the white abdominal line).
3. The abrupt increase in intra-abdominal pressure due to fault:
   • flatulence;
   • of indomitable vomiting;
   • of abdominal dropsy - a condition accompanied by accumulation of fluid in the abdominal cavity;
   • constipation( chronic constipation);
   • of large tumors localized in the abdominal cavity;
   • abdominal trauma;
   • pregnancy;
   • sharp slopes;
   • heavy physical exertion;
   • one-stage lifting of an unreasonably heavy object;
   • extreme degree of obesity;
   • is a prolonged and very severe cough that occurs in patients suffering from any nonspecific lung disease( eg, bronchial asthma or chronic obstructive bronchitis).
4. Dyskinesia - impaired peristalsis of the esophageal tube and other organs of the gastrointestinal tract - a phenomenon accompanying chronic gastroduodenitis, peptic ulcer of the stomach and duodenum, calculous cholecystitis and chronic pancreatitis.
5. Longitudinal shortening of the esophageal tube resulting from cicatricial inflammatory processes resulting from thermal or chemical burns, reflux esophagitis or the presence of peptic( esophageal) ulcers.
6. Pathologies, which are a consequence of intrauterine malformations of the fetus. These include the "chest" stomach and too short an esophagus.

Symptoms of

In half of patients, the hernia of the esophagus of the diaphragm proceeds either asymptomatically or with a minimal set of clinical manifestations. Asymptomatic nature of hernial protrusions of small size.

As a rule, they are detected quite accidentally in the course of diagnostic studies undertaken for other diseases.

• With a hernia that has reached an impressive size but is accompanied by a normal operation of the shut-off valves, the main clinical symptom is spasmodic pain coming from the sternum. Emerging in the region of the stomach, they gradually spread through the esophageal tube, in a number of cases irradiating( spreading) between the shoulder blades or in the back.
• With the appearance of shingles, the GADP can be masked for chronic pancreatitis in the acute stage.
• Hernia of the esophageal opening of the diaphragm can lead to the appearance of cardialgia - pain localized in the left side of the breast and having nothing to do with the pathologies of the heart muscle. A person who is not related to medicine can take them for the manifestation of angina pectoris or myocardial infarction.
• Approximately one-third of patients suffering from GPAP, the main occurrence of this disease is the presence of a disturbed heart rhythm, reminiscent of extrasystole or paroxysmal tachycardia. Through the fault of this symptom, patients are often given an erroneous cardiac diagnosis. All attempts to cure a non-existent heart disease result in failure.

To avoid mistakes in diagnosing ailment, when differentiating pain sensations, one should be guided by a number of specific features. With GVPD:

• the appearance of pain is observed immediately after eating, serious physical activity, taking a horizontal position and in the presence of flatulence;
• a sharp increase in pain occurs when the body tilts forward;
• softening or complete disappearance of pain occurs after a change in the pose, a deep breath, a few sips of water or the eruption.

When the hernia is infringed, very strong cramping pains arise behind the sternum, giving off to the area of ​​the scapula and accompanied by the appearance of:

• nausea;
• shortness of breath;
• vomiting with blood;
• tachycardia - a condition characterized by an increase in the heart rate;
• cyanosis of the mucous membranes and skin( cyanosis);
• hypotension - lowering blood pressure.

The development of GERD - gastroesophageal reflux disease - a constant companion hernia of the esophageal opening of the diaphragm provokes the emergence of a new complex of clinical symptoms. The patient appears:

• Belching with bile or stomach contents.
• Regurgitation( regurgitation of food, not preceded by nausea) occurring at night, as the patient assumes a recumbent position. Occurrence of this symptom is facilitated by a belated and very dense supper.
• Air belching.

The appearance of dysphagia is promoted by: eating too hot dishes, too cold drinks, bad habit hurriedly, without chewing, ingesting food or drinking liquids, taking one big sip.

The presence of

• with severe heartburn can be considered no less specific signs of GPOD;
• painful and persistent hiccups;
• burning sensation and pain in the root of the tongue;
• of a hoarse voice.

Patients with hiatal hernia usually have anemic syndrome, characterized by a combination of clinical signs( pallor of the skin, increased fatigue, tachycardia, weakness, dizziness) and laboratory anemia indicative of a low content of hemoglobin and red blood cells in the blood.

As a rule, anemia develops as a result of internal bleeding from the stomach and the lower parts of the esophageal tube that result from:

• of erosive gastritis;
• peptic ulcer;
• reflux esophagitis.

Degrees of the disease

The basis for isolating the degrees of hernia of the esophageal opening of the diaphragm is the data of an x-ray study, which allows to judge which part of the stomach( together with the adjacent structures) was above the diaphragm.

• The easiest - the first - the degree of pathology is characterized by the transition to the chest cavity only the abdominal part of the esophageal tube. The dimensions of the esophageal opening of the diaphragm are such that the stomach is unable to pass through it, so at this stage of the pathology the main digestive organ retains its normal physiological position.
• The second degree of is accompanied by a movement in the chest cavity not only of the abdominal esophagus but also of the upper part of the stomach: it is located at the level of the esophageal opening of the diaphragm.
• With the third degree of , all the organs located before in the abdominal cavity - under the diaphragm - migrate into the chest cavity. The group of these organs consists of the abdominal section of the esophageal tube, the cardiac valve and the whole stomach( its body, the bottom and the structures of the antrum section).

Diagnosis

Hernia of the esophageal opening of the diaphragm can be detected during the course of:

• Radiographic examination of the chest.
• Radiopaque diagnostic examination of the stomach and esophagus.
• Esophagoscopy - an endoscopic examination of the esophageal tube, carried out using an optical apparatus - an esophagoscope.
• Esophagogastroscopy is a diagnostic technique that allows to assess the condition of the mucous membranes of the stomach and esophagus. All manipulations are performed using a flexible optical tube - fibro-esophagogastroscope.

Photo of a hernia of the esophageal opening of the diaphragm on the roentgenogram of the

The roentgenological features of the GPOD include:

• high localization of pharyngeal sphincter;
• the location of the cardiac valve above the level of the diaphragm;
• movement of the sub-diaphragmatic segment of the esophagus into the thoracic cavity;
• increase the size of the diaphragmatic hole;
• delay of radiopaque substance in the structures of hernial protrusion.

The results of endoscopic studies generally indicate:

• movement of the esophagus and stomach from the sub-diaphragmatic space;
• the presence of symptoms of esophagitis( an ailment accompanied by inflammation of the mucous membranes of the esophagus) and gastritis.

To exclude the presence of esophageal tumors, an endoscopic biopsy of its mucous membranes is performed, exposing the tissue of the biopsy specimen to a morphological study. To reveal hidden bleeding from the intestinal tract, the patient's feces are examined for latent blood.

Esophageal manometry is of great importance in the diagnosis of GAPD, a diagnostic technique that examines the contractile activity of the esophageal tube and the coordination of its motor activity with the operation of sphincters( pharyngeal and cardiac).In evaluating the motor functions of the esophagus, the amplitude, duration and nature( it may be peristaltic or spastic) of its contractions are taken into account.

The results of esophageal manometry allow us to draw conclusions about how successful conservative treatment is.

To obtain data on the nature of the environment in the gastrointestinal tract, diagnostic techniques are used:

• Intra-gastroesophageal and intragastric pH-metry. In the course of these studies, designed to assess the secretory activity of the digestive tract, the acidity of gastric juice in different parts of the digestive system is measured, and the dynamics of the acid-base balance under the influence of certain medications is also studied.
• Impedanceometry is the study of the functions of the stomach and esophagus, based on measurements of impedance, which occurs between the electrodes of a special probe inserted into the upper sections of the gastrointestinal tract through the oral cavity.
• Gastrokardiomonitoringa - a combined electrophysiological study combining electrocardiography( a technique for recording the electric fields produced by the operation of the heart muscle) and measuring the acidity of the digestive juice.

Endoscopic signs of

Endoscopic signs of GPOD indicate the presence of:

• Reduced distance from the central incisors to the cardiac sphincter.
• Incomplete closure or gaping of cardiac pulp.
• Pathological formation( called prolapse of the gastric mucosa in the esophagus) - folds formed by the mucous membranes of the stomach and displaced towards the esophageal tube.
• Gastroesophageal reflux of stomach contents.
• A hiatal narrowing of the esophagus, called the "second entrance" into the stomach.
• The manifestations of gastritis and esophagitis.
• Herniated cavity.

How to treat a hernia of the esophagus?

In the first stage, methods of conservative treatment are used.

To eliminate the clinical manifestations of all concomitant diseases of the digestive system( gastritis, gastroesophageal reflux, ulcers, dyskinesia and erosions), an individual program of complex medical therapy is developed for each patient, using

• Antacids ( represented by Almagel, Maalox and Gastalum).
• Inhibitors of the proton pump ( esomeprazole, omeprazole, pantoprazole).
• H2-antihistamines ( most often ranitidine).
• Prokinetics , improving the condition of the mucous membranes of the esophagus( ganaton, motilium, trimebutin, motilac).
• Vitamins of group B , capable of accelerating the restoration of the structures of the stomach.

For the management of pain syndrome, non-steroidal anti-inflammatory drugs( represented by paracetamol, ibuprofen, nurofen) can be prescribed to patients. In some cases, the use of these drugs can provoke an increase in clinical manifestations, characteristic of gastroenterological diseases.

To enhance the effectiveness of drug treatment, patients are recommended:

• adhere to a sparing diet;
• to work on the normalization of weight;
• occupies a semi-sitting position during night's sleep( thanks to the raised head of the bed);
• to avoid any kind of physical exertion.

Surgical treatment of

Indication of the need for surgical intervention is the presence:

• full of ineffectiveness of drug treatment;
• complicated forms of diaphragmatic hernias;
• precancerous( also called dysplastic) changes in the mucous membranes of the esophagus.

There is a rather large number of options for surgical treatment of diaphragmatic hernias. For convenience, they are divided into groups, which include operations aimed:

• To suture the hernial opening( called the hernial portal) and strengthen the esophagus-diaphragmatic ligament. To this group of surgical interventions include cirrhraphy( surgery for suturing the legs of the diaphragm) and the plastic of the diaphragmatic hernia.
• To restore the acute angle between the abdominal esophagus and the bottom of the stomach. Such tasks are solved by the fundoplication operation. During its execution, the bottom of the stomach wraps around the esophageal tube. The result is a cuff that prevents the contents of the stomach from being thrown into the esophagus.
• On the fixation of the stomach. In the course of gastropexy, this kind of surgical intervention is called - the stomach is sutured to the posterior or anterior abdominal wall.
• To remove a large part of the esophagus( within healthy tissues) during its resection.

Diet after operation

• During the first day after surgery, the patient is allowed to drink water( not more than 300 ml).
• On the second day, a small portion of low-calorie soup is offered.
• Gradually, soft food is introduced into the diet of the patient, able to move without difficulty along the esophageal tube.
• The temperature of the consumed food and drinks is of great importance: it should be as close as possible to body temperature. Compliance with this requirement will help the food to pass without difficulty through the cardiac valve that has swelled after surgery. At higher or lower temperatures, it can contract and not pass food into the stomach.

Compliance with a strict post-operative diet is recommended for eight weeks.

After this, go to a softer version of the diet, which should be followed for half a year. Further, the need for diet and medication is, as a rule, eliminated. Nevertheless, the question of the possibility of returning to the previous method of nutrition can be solved only by the attending physician.

Reviews

Catherine:

My mother's hiatus of the esophageal region of the diaphragm was found when a third of the stomach already migrated from the sub-diaphragmatic space. On the family council, it was decided to do a laparoscopic operation. After two hours( this is how much the operation lasted), a doctor came to us and said that the operation was successful. My mother felt well and was discharged on the third day. She had four small incisions on her body. Since the surgery, only two weeks have passed, but my mother's condition is improving every day. We observe a special diet and hope for a full recovery.

Sergey:

I want to share my joy about getting rid of hernia of the esophageal opening of the diaphragm. For a whole month now, I feel like a different person. My heartburn and chest pain disappeared, the food stopped throwing into the esophagus and I forgot about the increase in pressure after each meal. The postoperative diet has yet to be adhered to, but, realizing how necessary it is, I am optimistic about the future.

The cost of

The cost of surgical treatment of diaphragmatic hernias in Moscow clinics depends on the clinical level of the medical institution, the qualifications of the specialists working in it and its equipment with modern high-tech equipment.

Depending on this, the spread of transaction rates can be quite impressive.

• The cost of surgery for resection of the esophagus ranges from 26 000 to 80 000 rubles.
• For fundoplication the patient can pay from 25 000 to 135 000 rubles.
• The average cost of plasty of the diaphragmatic hernia is 48,000 rubles.
• Approximate cost of video endoscopic hernia removal with mesh setting( laparoscopic surgery) - 30 000 rubles. This amount does not include the cost of a mesh implant and an endoscopic herniostepler - a tool designed to connect the tissues and attach the mesh to them.

Treatment with folk remedies

The use of folk remedies can not eliminate a hernia, but with their help one can achieve some relief of its manifestations and speed up the process of digesting food.

The use of herbal decoctions and teas helps neutralize the increased acidity of gastric juice, accelerate the progression of the coma along the gastrointestinal tract, and significantly reduce the level of gassing in the intestine.

The most effective in alleviating the symptoms of GVAP are:

• Tea made from peppermint or chamomile, eliminating heartburn, reducing gas formation and soreness.
• Broths from medicinal collections containing sage, bark of red elm or oak, mother-and-stepmother, cuff, flaxseed and medicinal marshmallows. Porridge from the seed of flax. By enveloping the mucous membranes of the gastrointestinal tract, it soothes irritation and helps to cope with heartburn.
• A decoction of carrot seeds helps to reduce discomfort in the esophagus and stomach structures.

Menu

Since the hernia of the esophageal opening of the diaphragm flows against the background of intolerable heartburn, it is necessary to exclude from the diet of the patient products capable of provoking its occurrence. Also undesirable are beverages and dishes, the use of which leads to bloating.

Patient with GOPOD should stop using:

• Any greasy, fried and spicy dishes.
• Fat products from cow's milk.
• Butter and vegetable oil.
• Coffee, chocolate and cocoa.
• Luke( both green and onion) and garlic.
• Coarse fiber found in whole nuts and grains, hard raw fruits and vegetables, bran.
• Dishes( including beverages and sauces) from tomatoes.
• of Salt.
• Sukharikov and chips.
• Ice cream. Mustard, ketchup and vinegar.
• Any carbonated drinks.

The list of products that can help the sick person's body to cope with the disease is no less impressive. The patient's diet with HFAP requires the presence of:

• Kash, cooked in skim milk or water.
• Dishes made from low-fat goat and cow's milk.
• Meat and fish of lean varieties.
• Baked or wiped apples.
• Fresh bananas.
• Baked potatoes and carrots.
• Egg white.
• Green peas and green beans. Broccoli steamed.
• Soft biscuits.
• Baking from rice flour.
• Marmalade, marshmallow, jelly and pastille.

The basic rules for feeding a patient suffering from diaphragmatic hernia include several items that require mandatory compliance:

• Overeating is unacceptable. The volume of food eaten at one time should not exceed 250 g.
• The intervals between meals should not be more than three hours.
• Dinner, eaten a couple of hours before bedtime, should be easy.
• After eating, the patient with GVPD should never go to bed, so he is recommended to walk a little( preferably in the forest or park).
• Any squats and slopes after meals are prohibited.

Exercises

• The best physical exertion for patients with diaphragmatic hernia are walking tours( certainly in the fresh air).During walking it is desirable to maintain a fast pace, following the correctness of posture and tension of abdominal muscles. Such walking will help to somewhat reduce the feeling of constant pressure in the chest.
• Very useful low jumps in place. Together with the vertical position of the body, they facilitate the return of the stomach to a normal physiological position.
• To strengthen the abdominal muscles in the complex of therapeutic gymnastics necessarily include slopes and squats. The main condition is moderation and lack of tension.
• Pilates or yoga classes are ideal for patients suffering from GPAP, since they help to strengthen not only individual muscles, but also the whole body. Having experienced severe pain, a patient with a diaphragmatic hernia can try to cope with it as follows: after drinking a glass of pure water, one should stand on a small eminence( the bottom step is quite suitable) and make several shock-absorbing jumps.

  The weight of the water, weighting the stomach, will help him to sink down and take the correct position.

  What is dangerous for a hernia of the esophageal opening of the diaphragm?

  • The transfer of the contents of the stomach into the lumen of the respiratory tract is fraught with the development of aspiration pneumonia, tracheobronchitis( a diffuse inflammatory process affecting the bronchi and trachea) and bronchial asthma.
  • The greatest danger is the probability of infringement of organs penetrated into the thoracic cavity through an enlarged aperture of the diaphragm: esophagus, stomach and even intestinal loops. This condition is associated with the emergence of very severe pain in the chest, a violation of the swallowing function, the appearance of nausea and vomiting.
  • GVAP can lead to the development of esophageal ulcers, to scar scarring or perforation of the esophageal tube. These pathologies can trigger the onset of internal bleeding( esophageal or gastric), which is a serious threat to the life of the patient.
  • Complicated flow of diaphragmatic hernia can result in the development of reflux esophagitis - a very dangerous disease, accompanied by the constant ingress of gastric juice into the lumen of the esophagus. With prolonged exposure to concentrated hydrochloric acid, which is part of the digestive juice, malignant degeneration of the cells of the esophageal tube mucosa may occur, fraught with the appearance of pathological neoplasms and the development of cancer.

  Prognosis and prophylaxis

  In case of untimely diagnosis and with erroneous treatment tactics, a hernia of the esophageal opening of the diaphragm can provoke the appearance of:

  • Reflex angina pectoris.
  • Perforations of the esophageal tube.
  • Peptic ulcers of the esophagus and stomach.
  • Various forms( erosive, catarrhal, ulcerative) esophagitis.
  • Cicatricial esophageal stenosis.

  The package of preventive measures should include:

  • Normalization of body weight.
  • Strict adherence to the correct diet, prescribing to eat every three hours.
  • Complete elimination of alcohol and tobacco smoking.
  • A full night's sleep on a comfortable bed with an elevated headboard( during sleep the patient should be either in a semi-sitting position or on his right side).
  • Refusal from intensive physical exertion. From the gymnastics complexes it is necessary to exclude exercises with the slope of the body forward, paying special attention to strengthening the abdominal muscles.
  • Wearing comfortable clothes. Tight corsets, belts and bandages, tightening the belly, should disappear forever from the wardrobe.
  • Normalization of the intestine and prevention of constipation.
  • Drink 120 ml of mineral water( without gas) one hour before each meal. Ideal option is the medical-table water of the trade mark "Borjomi".

  Video transmission about a hernia of the esophageal aperture of the diaphragm: