1. DIAPHRAGM AND HIATUS HERNIA

2. Anatomy of diaphragm
Diaphragm
Diaphragmatic communications

5. Physiology

6. Normal anatomy of LES

7. Normal anatomy of LES

8. Normal anatomy of LES

9. Hernia-peritoneum diverticulum

10. Clasification
Congenital
Accuired

11. Congenital hernia

12. Congenital diaphragmatic hernia

13. Incidence 1 : 2000-5000 live birth
8 % of all major congenital anomalies
mortality rate nearing 70 percent
CDH accounts > 1% of total infant mortality in USA
Cost per new case CDH = $

14. Diaphragm Development

15. Causes The cause of CDH is largely unknown
CDH can occur as part of a multiple malformation syndrome
Karyotype abnormalities have been reported in 4% of infants with CDH

16. Congenital Diaphragmatic Hernias (CDH)
Types of Congenital Diaphragmatic Hernias (CDH)
Bochdalek
Morgagni
Diaphragmatic eventration
Central tendon defects

17. Bochdalek Hernia Postero-lateral diaphragmatic hernia
Most common manifestation of CDH, accounting for more than 95% of cases
Majority of Bochdalek hernias (80-85%) occur on the left side of the diaphragm
A failure of the diaphragm to completely close during development.
Herniation of the abdominal contents into the chest
Pulmonary hypoplasia

18. Morgagni Hernia anterior defect of the diaphragm
referred to as Morgagni’s, retrosternal, or parasternal hernia
accounts for approximately 2% of all CDH cases
characterized by herniation through the foramina of Morgagni which are located immediately adjacent to the xyphoid process of the sternum
majority occur on the right side of the body and are generally asymptomatic

19. Diaphragmatic eventration
abnormal displacement (i.e. elevation) of part or all of an otherwise intact diaphragm into the chest cavity
diaphragm is thinner in the region of eventration, allowing the abdominal viscera to protrude upwards
thinning is thought to occur because of incomplete muscularisation of the diaphragm
Minor forms of diaphragm eventration are asymptomatic

20. Congenital Diaphragmatic Hernias (CDH)
Left sided CDH is a cm postero-lateral defect
Right lobe of liver can occupy most of hemithorax in rt side defect
Hepatic veins may drain ectopically into right atrium
Lung and liver may be fused

21. Prenatal Diagnosis
ultrasonography diagnosis (as early as the second trimester)
Mediastinal shunt
Viscera herniation (stomach, intestines, liver*, kidneys, spleen and gall bladder)             
Abnormal position of certain viscera inside the abdomen
Stomach visualization out of its usual position
Intrauterine growth retardation*
Polyhydramnios*
Fetal hydrops*
* bad prognosis

22. Fetal diafragmatic hernia: Ultrasound diagnosis

23. Prenatal MR Imaging - single-shot turbo spin-echo (HASTE)- of congenital diaphragmatic hernia

24. Prenatal MR Imaging of congenital diaphragmatic hernia

25. Pulmonary hypoplasia

26. Anatomopathology show of CDH

27. Prenatal Counseling multidisciplinary team
patient's obstetrician
perinatologist
geneticist
surgeon
social worker

28. Prenatal management Glucocorticoids Thyrotropin-releasing hormone
Fetal surgical therapy (Antenatal surgical intervention, In utero tracheal occlusion )

29. Delivery Room Management
affected infants should be delivered in a specialized center
require positive pressure ventilation in the delivery room.
to prevent distension of the gastrointestinal tract and further compression of the pulmonary parenchyma, a double-lumen nasogastric or orogastric tube of large caliber is placed to act as a vent.
early intubation

30. Postnanal Diagnosis Respiratory distress Scaphoid abdomen
Auscultation of the lungs reveals poor air entry
Shift of the heart to the side opposite

31. Postnanal Diagnosis left-sided CDH
Radiograph in a male neonate shows the tip (large arrow) of the nasogastric tube positioned in the left hemithorax. Note the marked apex leftward angulation of the umbilical venous catheter (small arrow).

32. Right congenital diaphragmatic hernia
Radiograph in a male neonate shows that the nasogastric tube (arrow) deviates to the left of the thoracic vertebral bodies as it passes through the inferior portion of the thorax

33. Postnatal management Mechanical ventilation Nitric Oxide Surfactant
Surgery

34. Operative approach

35. The defect in the diaphragm

36. Patch repair of a large defect

37. Evolving Therapies In utero repair Liquid ventilation
Pulmonary transplantation
Pharmacology
Prostacyclin derivatives
Calcium channel blockers
Phosphodiesterase inhibitors

38. Prognosis
Pulmonary recovery: When all resources, are provided, survival rates range from 40-69%.
Long-term morbidity: Significant long-term morbidity, including chronic lung disease, growth failure, gastroesophageal reflux, and neurodevelopmental delay, may occur in survivors.

39. ADULT DIAPHRAGMATIC HERNIA

40. Classification ?Asymptomatic congenital diaphragmatic hernia
Posttraumatic or postoperative
Hiatus hernia

41. Posttraumatic hernia

42. Symptoms Uncomplicated: Complications: Similar woth GERD
Respiratory symptoms
Cardiac arrhythmia, ischemic heart disease\
Complications:
Strangulation: acute respiratory and digestive symptoms, very difficult to assess on clinical examination

43. Diagnostic Plain thoracic X-Ray Nasogastric tube + X-ray
Barium or Gastrographin studies if non-emergency
CT-scan

44. Treatment Approach: Reintegration of viscus
Laparotomy vs laparoscopy
Thoracotomy vs thoracoscopy
Urgent vs chronic disease
Reintegration of viscus
Resection of peritoneal sac
Close the defect in diaphragm
Suturing
Mesh

45. HIATAL HERNIA

46. Hiatal Hernia Defined (Also called Diaphragmatic Hernias)
Protrusion of the stomach upward into the mediastinal cavity through the esophageal hiatus of the diaphragm
Sliding
90% of cases
Rolling (paraesophageal)
In a sliding hiatal hernia, the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus. This is the more common type of hernia. Sliding hiatal hernias develop from muscle weakening in the esophageal hiatus.
The paraesophageal hernia is less common, but is more cause for concern. The esophagus and stomach stay in their normal locations, but part of the stomach squeezes through the hiatus, landing it next to the esophagus. Although you can have this type of hernia without any symptoms, the danger is that the stomach can become "strangled," or have its blood supply shut off. Paraesophageal hernias are thought to develop from an anatomic defect occurring when the stomach is not properly anchored below the diaphragm rather than from muscle weakness. 46

47. Sliding Hiatal Hernia
The esophagus passes through the diaphragm and connects to the stomach. When a sliding hiatal hernia is present, part of the stomach moves up through an opening (hiatus) in the diaphragm. The presence of a hiatal hernia increases the risk for gastroesophageal reflux
The major concern in a client with a sliding hernia is the development of esophageal reflux and its complications. Symptoms associated with a sliding hiatal hernia are worsened by positions that favor reflux, such as lying supine or bending. 47

48. Paraesophageal Hiatal Hernia
The fundus and possibly portions of the stomach’s greater curvature, rolls through the esophageal hiatus and into the thorax beside the esophagus
In a rolling or Paraesophageal hiatal hernia the herniated portion of the stomach may be small or quite large. Reflux is rarely a concern with this type of hernia but the risks of volvulus (bowel twisting), obstruction, and strangulation are high.
The development of iron deficiency anemia is common because of slow bleeding secondary to venous obstruction causing the gastric mucosa to become engorged and ooze 48

49. A Comparison of the normal stomach, sliding hiatal hernia and rolling hiatal hernia

50. Diagnostic Tools Barium Swallow CXR Endoscopy with biopsy
Stool for quiac
Esophageal manometry
The barium swallow study with fluroscopy is the most specific diagnostic test for identifying hiatal hernias. Clients with sliding hernias usually expereince symptoms of reflux. Therefore, any tests used for diagnosing GERDS may be used for evaluating the extent of reflux and the degree of esophageal damage. 50

51. Diagnostic Tools
The barium swallow study with fluroscopy is the most specific diagnostic test for identifying hiatal hernias. Clients with sliding hernias usually expereince symptoms of reflux. Therefore, any tests used for diagnosing GERDS may be used for evaluating the extent of reflux and the degree of esophageal damage. 51

52. Key Features of Hernias
Paraesophageal hernia
Feeling of fullness and breathlessness after eating
Feeling of suffocation
Cheat pain that mimics angina
Symptoms worse in recumbent position
Sliding hiatal hernia
Heartburn
Regurgitation
Chest pain
Dysphagia
Belching 52

53. Symptoms

54. Complications Slow bleed Anemia Pulmonary Aspiration
Pulmonary symptoms similar to asthma may be triggered by episodes of aspiration, particularly at night. 54

55. Risk Factors Increased intra-abdominal pressure Age Obesity Pregnancy
Bending
Coughing
Weight lifting
Age
Hiatal hernia is one of the most common disorders affecting the upper GI tract, and it affects women more often than men. Hiatal hernias have been reported in up to 20% of adults. 55

56. Medical Treatment Goals
Aimed at relieving symptoms and prevent complications
Bleeding
Reduce regurgitation of stomach contents into esophagus
Medications
Includes antacids and histamine receptor antagonists (Pepcid and Reglan)
Neutralizes stomach acidity
Decrease acid production
Clients may be managed either medically or surgically. The choice of management is based on the patient’s symptoms. Sliding hiatal hernias are most commonly treated medically. Large paraesophageal hernias can become strangulated or obstructed, therefore early surgical repair is encouraged.
Nonsurgical management includes drug therapy, similar to that used for the treatment of GERDS (see Chart 58-3 page 1264). 56

57. Surgical Intervention
Used when medical therapy fails to control symptoms
Surgery is extensive and produces frequent complications
Hiatal hernia tends to recur after surgery
Laparoscopic Nissen Fundoplication
Laparoscopic Nissen Fundoplication is the most common surgical technique for hiatal hernia repair. A small percentage of patients are not candidates for the laparoscopic approach and will need the open procedure. In laparoscopic surgery the repair is performed through several (usually 5) one half inch incisions in the abdomen. 57

59. In this type of surgery the surgeon wraps a portion of the stomach fundus around the distal esophagus to anchor it and reinforce the lower esophageal sphincter. 59

60. Postoperative Care Risk for bleeding, infection and organ injury
Respiratory Care
NG tube Management
Nutritional Care
Clients have a nissan fundiplication are at risk for bleeding, infection, and organ injury, although these problems are not common. The major nursing responsibility is to observe for these complications and provide health teaching as described in Chart 58-6 on page 1268. 60

61. Results

62. Complications Temporary dysphagia
Gas bloat syndrome (avoid carbonated beverages)
Atelectasis, pneumonia
Obstructed NG tub
Reccurrent GERDe
RARE:
Mediastinitis
Fistula
In temporary dysphagia the client has difficulty swallowing when oral feeding begins, this is temporary and should resolve. If the dysphagia is persistent this usually indicates that the fundoplication is too tight, and dilation may need to be done.
In gas bloat syndrome the patient has difficulty belching to relieve distention
With atelectasis and pneumonia the patient develops dyspnea, chest pain, or fever.
With an obstructed NG tube the patient experiences nausea, vomiting, and abdominal distention. The NG tube does not drain for some reason. 62

63. Complications