Esophageal diverticula

The esophageal diverticula are the sacciform outpouchings of the esophageal wall, which filled with mucus and undigested food.

 

Etiology and pathogenesis

The conducting pathogenic moment in occurrence of esophageal diverticula is the increase of intraesophageal pressure proximal to muscle sphincters, which gradually results in herniation in weak sites of the esophageal wall. Such mechanism of formation is characteristic for pulsion diverticula. Traction diverticula are formed as a result of paraesophageal inflammatory and sclerotic processes, which tract esophagus to other organs, more often - with the right bronchus. During their motions owing to a traction esophageal diverticula also are gained.

Zenker's diverticula in advanced cases are great in size. There are three stages in their development:

1) outpouching of mucosa;

2) formation of a globular sack;

3) enlargement of diverticulum with further descending in mediastinum.

 

Pathology

The restricted blind herniation of the wall of esophagus could be single or multiple, ring-shaped, cylindrical, oval or sacciform-shaped. The muscle coat atrophies, that makes difficult differentiation between true and false diverticula. The latter caused by inflammatory processes. In such cases the paraesophageal scarring resulting from extrapharyngeal abscesses, mediastinitis, specific and nonspecific inflammatory processes of bifurcational lymph nodes (traction diverticula) are revealed.

The small size of the opening of pouch, for example, in globular diverticula, leads to congestion of contents with the further development of inflammation (diverticulitis erosive, catarrhal, gangrenous, purulent).

 

Classification

1.     According to the origin:

a)     congenital;

b)    acquired.

2.     According to number (fig 1.5.2):

a)     single;

b)    multiple.

3. According to histological structure:

a)     true (have all layers of esophageal wall);

b)    false (absent muscular layer of esophageal wall).

4. According to localization:

a)     pharyngoesophageal (Zenker's);

b)    bifurcational;

c)     epiphrenic.

5. According to the clinical course:

a)     complicated;

b)    uncomplicated.

 

Symptomatology and clinical course

Clinical manifestation of the esophageal diverticula, as a rule, connected with the occurrence of complications.

The symptomatology of Zenker's diverticula depends on the stage of development and their size.

Salivation, cervical dysphagia, difficult swallowing and cough usually occur in advanced stages of the diverticulum.

The dysphagia is frequently caused by congestion of food in diverticulum. Also a compressible mass in the neck usually on the left side is frequently revealed. The patients should press this mass to swallow the food and sometimes make unusual movements by neck in order to empty the diverticulum. The gurgling sound when the patient is eating and foul-smell from the mouth resulting from decay of undigested food in diverticulum cause the patient to alter social activities.

The sign "of a wet pillow" results from increased salivation and nocturnal discharge of saliva and mucus from the mouth.

Bifurcational diverticula are usually less 2 cm in size and therefrom rarely complicated and clinically manifested. At its greater size the complications can arise rather frequently and determine the course and manifestations of the disease.

The epiphrenal diverticula can achieve considerably size, and more frequently complicated by diverticulitis. Being filled with food, such diverticulum can compress cervical organs, and sometimes is complicated with achalasia.

The diagnosis is confirmed by the findings of barium swallow, and also esophagoscopy (fig 1.5.3-5).

 

Variants of clinical course and complications

Diverticulitis. The anginal pain, or the pain in epigastric region, which can resemble stenocardia or gastric disorders, belching, are the chief manifestations. Sometimes observed nausea and vomiting.

The perforation of diverticulum can be directed into pleural space, trachea, bronchus or pericardium. The clinical picture depends on the place of perforation. In part the perforation in trachea or bronchus results in occurrence of esophago-bronchial fistula. Clinically such complication is commonly shown by cough during meal. An everlasting esophago-bronchial fistula can cause the aspiration pneumonia with the further abscessing.

Bleeding from diverticula frequently results from erosion of esophageal mucosa on the background of diverticulitis. Nevertheless such bleedings, as a rule, are not profuse and rather easily stopped by conservative treatment.

Malignancy rarely occurs and most often as the outcome of recurrent diverticulites.

 

The diagnostic program

1. Anamnesis and objective examination.

2. General blood and urine analyses.

3. Coagulogram.

4. Chest X-radiography.

5. Roentgenoscopy of esophagus and gastrointestinal tract.

6. Fibrogastroduodenoscopy.

 

Differential diagnostics

Functional diverticula (pseudodiverticula). Their clinical manifestations resemble a diffuse idiopathic esophagospasm. Intermittent dysphagia, which usually arises after meal or strong excitements, are the sings of pseudodiverticula. A retrosternal pain, which accompanied them, can result in misdiagnosis of stenocardia.

Stenocardia. It is characterized by pain attacks with irradiation in the left arm and left scapula, feeling of fear. After taking of nitroglycerin the pain, and fear, as a rule, disappear. In contrast with stenocardia, the retrosternal pain caused by a spastic stricture or diverticulum of esophagus, is characterized by feeling of compression deeply inside, which usually more expressed in the back. There is no obvious sensation of fear, irradiation of pain in arm and relief after nitroglycerin. Usually it is accompanied by disturbances of swallowing, sometimes vomiting, after that the pain frequently disappears.

 

Tactics and choice of treatment

The treatment of pharyngoesophageal diverticula is surgical. Conservative therapy is indicated in case of severe concomitant pathology, the patient's refusal of operation or there are no conditions for its performance. In such cases mechanically sparing diet with washing down of solid food.

The bifurcational diverticula require operative treatment only in one patient in ten. The indications for such operation are frequently recurrent diverticulites, bleeding, perforation, esophago-bronchial fistula or suspicion on malignancy.

Accesses. In order to expose pharyngoesophageal diverticula the cervical access along the anterior border of the sternocleidomastoid muscle is applied; in case of bifurcational diverticula right-sided posterolateral thoracotomy in V intercostal space is performed; in epiphrenal diverticula left-sided posterolateral thoracotomy in V intercostal space (fig 1.5.6).

The essence of the operation consists of the following: the esophagus mobilized proximal and distal to diverticulum; after the exposure the latter is sutured or stapled near its basis and cut off. The line of suturing is covered by muscular layer of esophageal wall.

 

Achalasia of the cardia

Achalasia of the cardia is the disease, which is characterized by failure of the lower esophageal sphincter to relax with swallowing.

 

Etiology

The cause of this disease is still unknown. Among the underlying mechanisms are the psycho-emotional trauma, disturbance of parasympathetic and sympathetic innervation and influence of vegetotrophic substances on muscular fibers.

 

Pathology

Morphological changes depend on the stage of the disease, character of inflammation and mainly concern nervous and muscle fibers. Thus the phenomena of the thickening of axial cylinders of nervous fibers progressively increase, with the development of their fragmentation and vacuolization. The working hypertrophy of muscular fibers is finished by the dystrophy of myocytes and the development of sclerosis. The latter is contributed by inflammation, mainly of immune character. In final stage a mediastinal pleura, paraesophageal fat and diaphragm consolidate and knitted together.

 

Classification

Four stages of the disease are distinguished:

1)    functional spasm without esophageal dilation;

2)    constant spasm with a moderate esophageal dilation and maintained peristalsis;

3)    cicatrical changes of the wall with expressed esophageal dilation, the peristalsis is absent;

4)    considerable esophageal dilation with sigmoid-shaped elongation and the presence of erosive changes of esophageal mucosa.

 

Symptomatology and clinical course

Dysphagia in the onset of the disease wears a temporary intermittent character with further permanent interchange. The passing of food after several swallows delayed on the level of a lower part of breastbone. In some cases during meal the dysphagia arises suddenly without any cause. The majority of the patients with dysphagia swallow better warm or hot food.

Esophageal vomiting (regurgitation) is the outcome of accumulation in esophagus of two and more l. of fluid. In initial stages of the disease the regurgitation can arise during or at once after meal and is accompanied by discomfort pain sensations. In advanced stages observed regurgitation with a rotten smell. The regurgitation can occur during sleeping the sign "of a wet pillow".

Splashing sounds and gurgling behind breastbone are rarely observed.

The sign of nocturnal cough arises owing to aspiration of fluid from esophagus into trachea. Thereby, the patients try to sleep in a sedentary position.

Pain and sense of tightness in the chest is the result of spasm and esophageal distention. With the developing of esophagitis, the pain wears a burning character.

Loss of weight is the outcome of prolonged disturbed food intake.

It is necessary to consider roentgenological contrast examination with barium swallow as the chief method, which enables to confirm the diagnosis. In the beginning of the disease revealed an inappreciable esophageal dilation and temporary delay of barium above the level of the inferior esophageal sphincter. In advanced stages of the disease observed a considerable esophageal dilation and elongation with a long delay of barium. Contours of a distal constricted part of esophagus described as the "rat tail" or "bird-beak" sign, without filling defects (fig 1.5.8-9).

The endoscopic procedure reveals erosive changes of esophageal mucosa and enables to take a biopsy to rule out malignancy. Frequently in advanced stages it is failed to pass by endoscope a constricted part of esophagus and cardia.

 

Variants of clinical course and complications

The disease is characterized by remittent course with the change of the periods of dysphagia from inappreciable to intensive. Even in advanced stages in minority of patients observed a latent course with complete disappearance of dysphagia in considerable esophageal dilation and cicatrical stenosis of cardia. Nevertheless later (from several months to several years) there comes an exacerbation of the disease with more severe course.

The bleedings arise owing to complications of erosive esophagitis at long duration of the disease.

The malignancy occurs in the patients with phenomena of a chronic esophagitis and chronic character of the disease.

Pneumonia, abscesses, bronchiectases, atelectases and pneumosclerosis are frequently the outcomes of decreasing pulmonary excursion which results from compression by dilated esophagus.

 

The diagnostic program

1.     Anamnesis and physical findings.

2.     General blood and urine analyses.

3.     Chest X-radiography.

4.     Esophagogastroscopy.

5.     Contrast roentgenoscopy (barium swallow).

 

Differential diagnostics

Cancer of the lower part of esophagus and cardial part of stomach. The predominant place in differential diagnostics possesses X-ray examination. As opposed to achalasia, the cancer is characterized by irregular contours of constricted part of esophagus with filling defect. Endoscopic examination and biopsy allows to confirm the diagnosis.

Diaphragmatic hypotonia with inflection of esophagus also can be accompanied with dysphagia. However chest X-radiography enables to find out high standing of the left dome of diaphragm.

Pneumothorax. On the plain chest X-radiography the edge of dilated esophagus can resemble the edge of collapsed lung. Nevertheless in the patient with pneumothorax on the roentgenogram the lung pattern is absent.

 

Tactics and choice of treatment

Diet. The food should be semisoft, without pungent relishes, chemically inactive and enriched with proteins, fat, carbohydrates and vitamins.

The medicament treatment should include local anesthetics, spasmolytics, and sedative drugs. Atropin and other anticholinergic agents only increase the spasm of a cardial sphincter, therefrom their usage is undesirable. The medicament treatment results only in temporary relief.

Cardiodilatation is indicated in - stage of achalasia. It is one of the chief methods of the treatment of this pathology. The treatment is performed as follows: under local anesthesia by aerosol or solution of anesthetic agent (lidocain, trimecain) through constricted part of the cardia under roentgenological check cardiodilatator (metal, pneumatic) is passed. The air is pumped up in balloon making pressure 200-350 mm H2O. Repeated procedure is performed in 2-3 days. The course of dilatation includes 3-10 procedures, depending on obtained effect.

Surgical treatment is managed in -V stage of achalasia or in recurrence of the disease after dilatation.

Heller's method (esophagomyotomy). Operation is performed through upper median laparotomy or left thoracotomy in V intercostal space. After exposing of constricted part of esophagus and taking it on tourniquets a muscular layer of anterior wall of esophagus dissected down to mucosa. The myotomy performed from dilated part of esophagus to cardial part of stomach. The complete transsection of all muscular layer of esophagus, particularly its circular fibers, is the requirement of relapse prevention (fig 1.5.10).

The defect of a muscular layer of esophageal wall is covered with a gastric fundus or by means of interrupted suture or diaphragmatic flap.

Helerovsky's method. The operation is indicated for the patients with -V stage of the disease in case of considerable esophageal dilation, when performance of Heller's operation is impossible owing to cicatrical changes. However the indication for this operation should be restricted, because of frequent development of expressed esophagitis in postoperative period. The same accesses, as in Heller's operation are applied. Constricted part of esophagus to its dilation exposed and cardial part of stomach is mobilized. Dilated part of the esophagus is anastomosed with the fundus of stomach.

 

Esophageal sticture

The cicatrical esophageal stenosis can arise owing to chemical, thermal and radial burns, and as a result of esophagitis or peptic ulcers. The most frequent cause of cicatrical strictures is considered to be chemical burns of esophagus, which are usually the result of accidentally or purposely (suicide) drink of acids or alkalis.

 

Pathology

The morphological changes in esophageal burns pass four stages:

stage of acute esophagitis. Lasts from one to two months. It is characterized by edema and divestment of necrotic tissues. This stage is hazardous for erosive bleedings.

stage of chronic esophagitis. The ulcers of different sizes with granulating tissue in their bottom, focal constrictions of esophageal lumen are formed.

stage of cicatrical stricture of esophagus. Begins from 2-4th month and lasts to 2 years.

V stage of late complications. Develops in two years after the burn and is characterized by formed cicatrical stricture of esophagus.

 

Classification

According to the clinical course:

I. The period of acute manifestation has three degrees of severity:

1 - mild;

2 - moderate;

3 - severe.

. The latent period (false improvement).

. The period of cicatrization.

 

According to the depth of lesion:

I degree superficial burn with the damage of epithelial layer of esophagus;

degree the burn with the damage of entire mucosa of esophagus;

degree the burn damage of all layers of esophagus;

V degree the spread of postburn necrosis on paraesophageal tissue and adjacent organs.

 

Symptomatology and clinical course

The clinical signs of esophageal burn directly depend on the period of lesion and degree of gravity.

 

Acute period

The mild degree of clinical course manifests by satisfactory general state of the patient. At swallowing the patient feels a moderate pain, sometimes salivation, hoarseness. Roentgenologically the lumen of esophagus without changes, with free passage of barium, the mucous folds with regular contours, but in some places it is possible to observe its graduation. The esophageal peristalsis is maintained. As a rule, in 5-7 days the clinical manifestations of the burn disappear.

The moderate degree of gravity of acute period is characterized by acute substernal and pharyngeal pain at swallowing, repeated vomiting, feeling of fear and excitement. Tachycardia 120-130 beats/min. The body temperature rises to 39C. Oliguria develops frequently. Roentgenologically the esophagus dilated, but in some places can be constricted as a result of edema or spasm. The lumen is filled with considerable amount of slime. The contours of mucosal folds are irregular, the peristalsis is weakened or absent at all. If there will be no complication, in 10-15 days the clinical manifestation of the disease disappear and general state of the patient is improved.

Severe degree is characterized by the clinic of shock. Pulse of weak filling and tension, expressed tachycardia, acute substernal pain. The excitement of the patient is accompanied by feeling of fear, further transmits into adynamia, frequently the patients are unconsciousness. The skin is pale, covered with cold sweat. One patient in four except esophageal burns, suffers from burn of the stomach. The clinical course of the disease is worsened by oliguria, which can transfer into anuria, and also occurrence of other complications. It determines the unfavorable forecast.

The barium swallow in the majority of patients is problematic. Nevertheless if the general state of the patient allows to carry out it, on the first day after a burn already have been observed expressed manifestations of esophagitis: the esophagus dilated, mucosal folds are failed to reveal. The deposits of destructive changed tissues in the lumen of esophagus resemble the picture of filling defects; the peristalsis is absent, complete atony.

 

Latent period

This period is connected with replacement of necrotic tissues by granulations. The general state of the patient is improved. The acute signs disappear. The patient swallows freely, without feeling of discomfort at passage of food.

 

Period of cicatrize

It frequently lasts from 1 to 12 months. It is connected with replacement of granulations by cicatrical tissue that results in progressing of esophageal stricture and disturbance of swallowing at first of solid, and further of liquid food. Such strictures develop at the orifice of esophagus, in projection of tracheal bifurcation and in the place of gastroesophageal juncture. The passage of food through the constricted regions of esophagus is possible at first only due to careful grinding and watering, but further it is inefficient. Thereafter food delay in esophagus, choking, salivation, belching and vomiting develop. If the stricture is located in the lower part of esophagus, the vomitis can be of putrefactive character. Progressing loss of weight observed, which without correction can transfer into cachexia. The level and degree of the stricture, its extension circumstantiated after X-ray examination (fig 1.5.12).

 

Variants of clinical course and complications

The esophageal burns in 30 % of cases are accompanied by disturbances of valvular function of epiglottis. It in reinforced salivation causes the aspiration of fluid in trachea, infection of airways, development of bronchitis and pneumonia.

In 25 % of the patients the esophageal burn combined with gastric burn, mainly of its pyloric part. It can result in lot of complications, which sometimes prevail on the manifestations of esophageal burn. Especially dangerous among such complications of the early period is the gastric bleeding and perforation. The postburn stricture of pylorus belongs to the late complications.

Gastrointestinal bleedings usually occur in 3-10 days after the burn and are characteristic for the stage of formation of ulcers and granulations. Despite the rare arrosion of major vessels in such pathology, these bleedings are accompanied by considerable hemorrhage, because bleeds a considerable surface of the mucous membrane of esophagus or stomach.

Mediastinitis is mostly observed in deep burns of -V degree. It can be the outcome of perforation of esophagus or of hematogenic or lymphogenic spread of infection to mediastinum. The clinical manifestations mainly caused by a septic state of the patient and severe intoxication. The fever, difficult respiration, chest pain and tachycardia to 130 and more beats/min are observed. Temperature rises to 39-40 and has hectic character. Roentgenologically observed distention of the mediastinal shadow, sometimes detached mediastinal pleura. Pleurisy, pericarditis and lung abscesses can arise as the early complications of esophageal burns. To the late complications, except cicatrical stricture, it is necessary to regard tracheo-esophageal and broncho- esophageal fistula, and also malignancy of the cicatrical changed esophagus.

 

The diagnostic program

1. Anamnesis and physical findings.

2. X-ray examination of esophagus and stomach.

3. Chest X-radiography.

4. Endoscopic examination of esophagus, stomach and duodenum.

5. General blood analysis.

6. Coagulogram.

7. Biochemical investigation of plasma.

 

Differential diagnostics

It is necessary in advanced stages of esophageal and gastric strictures.

As there is the similar symptomatology, such cicatrical changes of the pyloroantral part of stomach can suggest pylorostenosis caused by peptic ulcer. The differential diagnosis is based on careful analysis of the history and endoscopic investigation of esophagus and stomach.

Esophageal cancer. As this pathology can have the similar roentgenological picture, it requires thorough differential diagnostics. Besides anamnesis and clinical manifestations, the question of the diagnosis finally confirmed by histological investigation of a biopsy material, obtained during endoscopy.

 

Tactics and choice of treatment

The treatment of esophageal burns first of all should be guided to save the life of the patient, and also to prevent the development of esophageal strictures. The first aid must be given as soon as possible after taking of the chemical substance, which have caused the burn. In such cases by means of gastric tube and great amount of water (to 10-15 l.) immediately wash out the esophagus and stomach. It is better to use for this purpose the neutralizing solutions. If the burn is caused by acid applied 2 % solution of sodium hydrocarbonatis, and in the burns by alkalis vinegar in the ratio 1:20 with water. For prophylaxis of shock and decreasing of psychoemotional excitement of the patient instituted anesthetizing agents. If asphyxia arise owing to edema of pharynx and epiglottis, a tracheostomy is performed.

The further aid the treatment of shock and hypovolemia by massive intravenous infusions (up to 4-5 l. per day) of saline solutions, solutions of glucose, dextrans and blood plasma. With the purpose of detoxycation also applied forced diuresis.

Antibacterial therapy is nominated for prevention of infection complications.

In first two days after the burn the patients get parenteral feeding. Nevertheless, if the swallowing is not disturbed, it is possible to add feeding by grinding cold food. The early application of enteric feeding can be as a weak bougienage of esophagus and simultaneous prophylaxis of cicatrical strictures. The development of complications requires the treatment of their liquidation.

In the third period of the course of disease it is important not to miss a possible formation of cicatrical stenosis of esophagus. In overwhelming majority at timely and correct performance of esophageal dilatation it is possible to achieve positive effect and avoid multistep and hazardous operations. The dilatation is carried out by special elastic thermolabile bougies. The first procedures of bougienage are necessary to carry out under the roentgenological check. It enables to prevent perforation of esophagus. The latter, as the complication of esophageal bougienage, can occur not only in places of cicatrical stricture, but also in the region of piriform sinus. Thereby the bougie penetrates in mediastinum and can result in mediastinitis. With the purpose of prevention of such complication the esophageal bougienage is better to carry out with conductor. It can be represented by a cord (thick thread), passed through the mouth and gastrostoma. The bougie should have the canal for conductor, nevertheless it is possible to apply the usual one with the loop, on its end.

In advanced cases if failed to reach the restore of esophageal patency by a bougienage, the esophagoplasty by stomach, small and large intestine is applied.

 

 

 

Diaphragmatic hernias

Diaphragmatic hernia represents herniation of abdominal organs through natural openings of diaphragm, its weak places or ruptures.

 

Etiology and pathogenesis

The cause of occurrence of congenital hernia is the disturbance of embryogenesis with transformation in anomaly of diaphragm. The acquired diaphragmatic hernia more often arise owing to age-dependent involution of diaphragm, its ptosis in the people with a mainly sedentary mode of life, increase of intraperitoneal pressure, obesity, cough, overfeeding, constipation, meteorism and pregnancy. The cause of sliding hernias can be draw of esophagus upward in reflux esophagitis owing to intensive contraction of its longitudinal musculature.

 

Pathology

As well as any hernia, diaphragmatic has hernial ring, hernial sac and hernial content. The tissues in the region of hilus, due to tension and pressure, result in atrophy and sclerosis. necrosis, chronic inflammation, adhesions of the hernial content can develop.

 

Classification

There are such types of hernia:

1)    congenital;

2)    acquired;

3)    posttraumatic;

4)    true;

5)    false.

. Diaphragmatic hernia.

I. Sliding (axial) diaphragmatic hernia:

1)    esophageal;

2)    cardial;

3)    cardiofundal.

. Diaphragmatic hernia of paraesophageal type:

1)    fundal;

2)    antral;

3)    intestinal (small and large intestine);

4)    combined intestinal-gastric hernias;

5)    epiploic.

. Huge diaphragmatic hernia:

1)    subtotal gastric;

2)    total gastric.

V. A short esophagus:

1)    acquired short esophagus;

2)    congenital short esophagus (thoracic stomach).

B. Parasternal hernias:

1)    retrosternal;

2)    retrocostosternal.

C. Lumbocostal diaphragmatic hernias.

D. Hernia of atypical localization.

 

Symptomatology and clinical course

The predominant manifestations resulting from sliding diaphragmatic hernia (about 90 % of diaphragmatic hernias) are the signs of gastroesophageal reflux. It is characterized by the pain behind breastbone or epigastric region. It more often appears in supine position after meal or after intensive physical exertion.

Heartburn is the second according to the frequency sign and caused by the injury of esophageal mucosa by gastric juice as a result in turn of gastroesophageal reflux.

Belching by air, as a rule, observed, which commonly results in pain relief and decrease of arching feeling in epigastric region.

Regurgitation arises owing to gastroesophageal reflux, which reaches pharynx and oral cavity. More often observed regurgitation by gastric acid or bitter liquid or food.

The sign of "lacing shoes" is expressed when the patient bends down after liquid food, and the latter is partially poured out into the mouth. It is caused by incompetence of the lower esophageal sphincter (gastroesophageal junction).

Nausea and vomiting are rare. The latter some patients cause by themselves to achieve some relief.

Dysphagia is rarely observed. More often it is the outcome of complications of diaphragmatic hernia (esophageal stricture, malignancy).

Roentgenological signs: 1) the sign of "bell"; 2) blunt His angle; 3) lack of air bubble of the stomach.

The clinical manifestations of paraesophageal, retrosternal or lumbocostal hernias basically depend on the character of organs, which the hernial sac contents, and their compressing by hernial ring. Sometimes the clinical course even of major hernias is asymptomatic, and they are occasionally found out during X-ray examinations. For the first time the disease can manifest under the influence of physical exertion, trauma, pregnancy, labors etc.

 

Variants of clinical course and complications

The sliding hiatal hernia commonly has typical clinical course and rather rich symptomatology, which enable to establish the diagnosis with a great degree of probability. Nevertheless occasionally gastroesophageal reflux as the sequel of a sliding hiatal hernia can result in misdiagnostics (stenocardia, acute cholelithiasis etc.).

The most often complications of sliding diaphragmatic hernia are gastric bleeding, peptic stricture of esophagus and malignancy.

The causes of the bleeding can be erosion and ulcers of stomach, which result from compression of the organ in esophageal hiatus. More often observed small bleeding, but at long-stand recurrent course they result in chronic anemia. The profuse bleeding arise rarely. The strangulation of a sliding diaphragmatic hernia never occurs.

Nevertheless for diaphragmatic hernias of other locations the most dangerous complication is naturally strangulation. Such pathology manifests by the signs of s strangulation intestinal obstruction. However the correct diagnosis frequently possible to establish only during operation.

 

The diagnostic program

1. Anamnesis and physical findings.

2. X-radiography of chest and abdomen.

3. Esophagogastroscopy with biopsy and histological investigation.

4. Contrast X-radiography of esophagus and stomach in three positions: upward, supine and upside-down position.

5. General blood and urine analyses.

6. Coagulogram.

 

Differential diagnostics

Stenocardia. Diaphragmatic hernias frequently cause the pain, which character not only the patient, but also doctor can identify as anginal. However in diaphragmatic hernia the pain more often is vague, spread to the stomach region and depends on body position. The pain, as a rule, arises in supine position and disappears, if the patient upward. More often it spreads to the right and anginal vice versa to the left. In diaphragmatic hernia the ECG can manifest the coronary failure, nevertheless standing up, owing to the stop of strangulation leads to disappearance of these pathological sings. The pain caused by diaphragmatic hernia does not relieve after nitroglycerin. In this case more effective and prompt is atropine.

Peptic ulcer. The pain in gastric and duodenal ulcer frequently localized in epigastric region with irradiation in the left or right hypochondrium. Nevertheless, it is characterized by periodicity, which caused by meal and disappears after the usage of soda.

Lung atelectasis, pleurisy, pneumonia are also should be differentiated with diaphragmatic hernia. Thus it is always necessary to remember, that the extrapulmonary shadow of supradiaphragmatic disposed hernia on a plain roentgenogram can resemble intrapulmonary. For correct diagnosis it is possible to recommend polypositional X-radiography, contrast roentgenography of esophagus and stomach.

Hypochromic anemia frequently associated due to repeated or permanent small bleedings. They are caused by a regional destruction a gastric mucosa. In the females of senior age if it is fail to explain genesis of the revealed anemia, it is necessary to think about the opportunity of diaphragmatic hernia and carry out appropriate X-ray examination.

 

Tactics and choice of treatment

The medical tactics toward diaphragmatic hernias of different localization essentially differs.

In case of sliding hiatal hernia the method of a choice is the conservative therapy:

1)    the diet the same, as in peptic ulcer;

2)    position of the patient during sleeping with elevated upside, during exacerbation sedentary;

3)    suppression of gastric secretion by administering of 2-blockers;

4)    neutralization of gastric acid;

5)    intensifying of evacuation of the food from stomach;

6)    avoidance of constipation;

7)    anesthetics and sedative agents.

The indication for surgical treatment of sliding diaphragmatic hernia is the considerable expression of clinical signs, diminish of patient's working capacity, fail of conservative treatment, bleeding, peptic stricture, malignancy.

Surgical treatment. Upper median laparotomy is mainly used. Nevertheless some surgeons prefer transthoracic accesses.

Stages of the operation:

1.     Drawing of the stomach into abdominal vacuity by disjunction of adhesions in the region of its cardial part, esophagus, excision of hernial sac.

2.     The plastics of esophageal hiatus of diaphragm (cruroplasty). The most widespread cruroplasty by Hill and narrowing of esophageal ring according to Garrington.

3.     Elimination of valvular failure of esophagocardial junction. The purpose of operation is to prevent gastroesophageal reflux by means of formation of His angle and esophagocardial valve. Also Nissen fundoplication is applied.

4.     Gastropexia fixation of gastric wall to parietal peritoneum.

Another tactics is applied in the patients with paraesophageal, parasternal and lumbocostal hernias. The method of choice is the surgery. Such tactics is explained by the hazard of strangulation. The essence of the operation consists of drawing down of hernial content (stomach, intestine, omentum) into abdominal cavity, removing of hernial sac and liquidation (suturing) of hernial ring.