What is Diaphragmatic Hernia?
A diaphragmatic hernia, or DH, is a condition where parts of the abdomen push through a hole in the diaphragm into the chest. It’s usually something a person is born with, but occasionally, it can occur later in life. It’s noted to appear in about 0.8 to 5 newborns for every 10,000 births. More often than not, the DH forming after birth is caused by a blunt injury or a penetrating one that tears the diaphragm. This tear can then lead to the abdomen bulging into the chest. There have also been instances of DH that happen spontaneously or due to medical procedures. Even though cases of DH occurring after birth are not common, they can be life-threatening and can carry a high risk of internal organs getting trapped and blood supply being cut off, leading to a death rate of as high as 31%.
When DH happens at birth, it is known as congenital diaphragmatic hernia, or CDH. With this condition, certain organs that should be in the abdomen are located in the chest instead due to an early developmental defect. Newborns with CDH usually start showing signs of breathing trouble within the first few hours after birth. At times, the breathing issues can be mild, but in some cases, they can be quite severe and life-threatening. The survival rates of infants with CDH have substantially improved thanks to early diagnosis and advanced newborn care, yet the risk of illness and death remains a concern.
Diaphragmatic injuries are relatively rare, affecting less than 1% of all trauma patients, and make up to 3% of all abdominal injuries. It is not common to find isolated injuries to the diaphragm. Rather, they are often found in combination with other serious abdominal or chest injuries. Even with an X-ray revealing the unlikely presence of abdomen organs in the chest, it is important not to overlook subtle cases. Medical professionals are advised to be vigilant to prevent potential debilitating health problems from delayed or missed diagnosis.
What Causes Diaphragmatic Hernia?
Acquired diaphragmatic hernia (ADH) usually happens because of trauma that results in damage to the diaphragm. It’s often a consequence of blunt trauma, but also from sharp injuries to the chest and abdomen areas. Even though the occurrence of diaphragm damage following such injuries is around 0.8 to 3.6%, hernias rarely develop subsequent to these incidents.
ADH can also be caused by medical interventions, although these instances are quite rare and are mainly observed in individual case studies. The operations that are most frequently linked with ADH are pediatric liver transplants and liver resections. Some other surgeries that have been documented to cause ADH in certain case studies are Nissen fundoplication, left colectomy, adrenalectomy, laparoscopy-assisted total gastrectomy, nephrectomy, and partial resection of the left lung using thoracoscopic surgery.
In some situations, individuals may develop spontaneous diaphragmatic hernias. These cases might not show any symptoms for years, only becoming noticeable when the hernias have grown quite large. There are some rare instances where ADH happened after a procedure called radio-frequency ablation for liver cancer and during pregnancy.
One major health review which looked at more than 53,000 patients with abdominal trauma, both blunt and penetrating, found that the diaphragm was injured in around 3% of cases. In the reported population, the reports suggested the ratio of sharp versus blunt traumatic diaphragm injuries was 2 to 1. The National Trauma Data Bank reports similar findings, where sharp injuries were more common than blunt ones (1 to 7% compared to 10 to 15%).
Risk Factors and Frequency for Diaphragmatic Hernia
Acquired diaphragmatic hernia is an uncommon condition. It usually results from an injury to the chest or abdomen, but this only happens in about 0.8 to 3.6% of these cases. Even then, not everyone who experiences this injury will develop a hernia. The number of people affected by diaphragmatic hernias from other causes isn’t well recorded, and is often only reported in individual case studies.
Signs and Symptoms of Diaphragmatic Hernia
Diaphragmatic hernia (ADH) often occurs following a sharp or blunt injury to the chest or stomach area. If there’s a known history of such traumas, the medical team should carry out imaging to assess the injury’s extent, which may show ADH’s presence. If there’s no known trauma, past surgeries might explain why the ADH has occurred. Persons with ADH may experience various signs and symptoms, which could include respiratory, digestive, or heart-related issues.
The pressure from abdominal organs entering the chest cavity can cause breathing difficulties and chest discomfort. Digestive symptoms might include recurrent stomach pain, a feeling of fullness after eating, vomiting, and other gastrointestinal problems that might hint at a blockage. In some spontaneous cases, the diaphragmatic hernia doesn’t cause symptoms and is only discovered through an unrelated imaging test.
- Respiratory issues
- Chest discomfort
- Recurrent stomach pain
- A feeling of fullness after eating
- Vomiting
- Gastrointestinal problems suggesting a blockage
- No symptoms in some cases with the condition discovered through unrelated imaging tests
Upon physical examination, a doctor might notice a sunken abdomen and a lack of breath sounds over the lower chest area, with bowel sounds being audible instead.
Testing for Diaphragmatic Hernia
Imaging is a critical tool for diagnosing a diaphragmatic hernia, which is a condition where an organ moves up into the chest through an opening in the diaphragm. There are several methods to do this, such as chest X-rays, ultrasounds, and MRIs, but the most preferred method is a CT scan.
In cases where the diagnosis is uncertain, doctors may recommend a laparoscopy or thoracoscopy, which are types of surgeries where a small camera is inserted through a small incision to look inside the body. For cases that are highly likely but the imaging results are unclear, direct surgical exploration may be used.
There are two main types of diaphragmatic hernias: those that are present at birth (congenital) and those that occur later in life (acquired). The methods of diagnosing these can be slightly different. In congenital cases, up to 60% of babies can be diagnosed before they are born during a routine ultrasound between the 18 and 22 week of pregnancy. If during this ultrasound the doctor notices certain anomalies, such as an excess of amniotic fluid or the presence of abdominal organs in the chest rather than in the abdomen, this could suggest a diaphragmatic hernia.
A left-sided hernia in the fetus might look like a mixed mass on the left side of the chest with a shift to the right of the heart and other organs. In many cases, the stomach won’t be visible in the belly. Instead, it may appear near the heart or towards the back of the chest. A homogeneous mass that reflects less sound near the heart might suggest a herniated liver, which can be further analysed with Doppler sonography.
A right-sided hernia might show a uniform mass on the right side of the chest. This doesn’t always lead to a shift of the heart to the left. The shifted liver’s appearance can mimic that of the lungs and may not be a reliable sign. However, the presence of fluids in the pleural space and intestines, as well as a leftward shift of the heart, may be indicative of a right-sided hernia.
After birth, any full-term infants showing signs of breathing difficulties should be evaluated for a diaphragmatic hernia. A chest X-ray can reveal the presence of abdominal organs within the chest, which can help in diagnosing the condition. Other signs include a mass effect or displacement of the heart, a reduced abdomen size, and positioning of a feeding tube within the chest. These signs can all hint at a possible diaphragmatic hernia.
Treatment Options for Diaphragmatic Hernia
If a person has an acquired diaphragmatic hernia, initially they will need to be stabilized correctly. After this, a surgical procedure will often be necessary to repair the issue. In most cases, surgeons perform this operation using an open abdominal approach with a method known as primary closure. In some scenarios, if the defect is too large to fix with non-absorbable stitches, a mesh repair can be used instead. If the hernia diagnosis is delayed, a thoracic (chest) approach might be more appropriate to prevent complications. In some cases, surgeons might combine a thoracic and abdominal approach, or even use a laparoscopic approach, depending on their expertise.
If a diaphragmatic hernia is a result of physical trauma, it’s recommended to administer pre-operative antibiotic therapy, typically with first-generation cephalosporins. For patients suspected of having a synchronized intestinal trauma, antibiotics that fight against anaerobes are given. If a large amount of blood loss occurs or if the surgery takes longer than 2 to 3 hours, prophylactic antibiotic therapy is usually repeated.
A person undergoing surgery for a diaphragmatic hernia usually has an incision made from the xiphoid (bony section at the lower end of the sternum or breastbone) to the pubis (front part of the pelvic bone). Doctors control any bleeding and abdominal spillage, and begin a thorough examination of the diaphragm. If any organs have moved into the chest through the hernia, they should be carefully repositioned back into the abdomen.
Chronic herniations are different and usually involve a hernia sac and severe dense adhesions. In these cases, the hernia sac should be dissected, and the abdominal organs carefully moved back into place, repairing any inadvertent damage immediately. The edges of the diaphragmatic defect are then held together with clamps and sutured either permanently or with absorbable stitches.
In some cases, a minimally invasive laparoscopic repair is considered more appropriate, particularly for patients with an isolated diaphragmatic injury. However, caution is required for patients with a history of previous surgeries and potential for tough adhesions. Using mesh is not always the standard repair method, but it could be considered in certain circumstances where significant tissue loss makes primary repair tricky. If the abdominal region is contaminated, proper cleaning and the use of flaps from the body’s own tissue like omentum or latissimus dorsi might be recommended. The use of mesh involves non-absorbable synthetic materials such polytetrafluoroethylene or polyethylene.
What else can Diaphragmatic Hernia be?
When it comes to diagnosing ADH, there are many possible conditions to consider. This is due to the fact that ADH can manifest in so many different ways, causing a wide array of symptoms. If we do an imaging test before considering other options, a diaphragmatic hernia might not be the first guess for what’s causing the patient’s symptoms. This might be different if the patient has had a traumatic injury.
Once we’ve done the imaging test, another possibility to think about is a type of cancer spreading, known as metastasis. This is especially relevant when there are small defects. Also, in the case when the patient hasn’t had any previous trauma, doctors should consider the possibility that the diaphragmatic hernia could be something the patient was born with, a condition known as congenital.
What to expect with Diaphragmatic Hernia
If a doctor fails to diagnose an acquired diaphragmatic hernia, there is a significant risk of death. This could be a result of the lungs being compressed, leading to respiratory failure, or due to the stomach or intestine’s blood supply being cut off, leading to tissue death or rupture.
The risk of death from the surgery to repair the diaphragm varies and can be anywhere from 5% to 50%, depending on other injuries that the patient may have. However, generally, the results after treatment are positive, with a low chance of the hernia happening again.
Possible Complications When Diagnosed with Diaphragmatic Hernia
Acquired diaphragmatic hernia, a condition where an organ pushes through a weak spot in the diaphragm, might cause several complications. These range from diaphragm rupture, sudden blocking of intestines, inability to breathe properly, entrapment of abdominal organs, compression of blood vessels, and severe heart complications.
Moreover, if the diagnosis is delayed, it might result in complications that cannot be reversed due to the extended presence of this hernia. This delay can potentially cause the strangulation (blocking of blood flow) of the abdominal organs and dire situations such as the blockage of the intestine, perforation (a hole in the intestine), and necrosis (death of tissue).
Common Complications:
- Diaphragm rupture
- Sudden blocking of intestines
- Inability to breathe properly
- Entrapment of abdominal organs
- Compression of blood vessels
- Severe heart complications
- Strangulation of abdominal organs
- Blockage of the intestine
- Perforation of the intestine
- Necrosis of tissues
Preventing Diaphragmatic Hernia
An acquired diaphragmatic hernia usually happens suddenly as a result of an injury. In such cases, emergency surgery is often the only way to save the patient’s life. Before the surgery, doctors should try to get permission from the patient or their family, and explain the potential risks involved.
However, it’s also important to understand that not performing the surgery could lead to serious complications, including the risk of death. Therefore, it’s crucial to weigh the possible consequences of the surgery against the risks of not having it.