Diaphragmatic hernia: Difference between revisions

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== Anatomy and classifications ==
== Introduction ==
Diaphragmatic [[hernia]]<nowiki/>s are protrusions of abdominal organs such as small intestine, stomach, spleen, and part of the liver in the thoracic cavity.<ref>Chandrasekharan PK, Rawat M, Madappa R, Rothstein DH, Lakshminrusimha S. [https://pubmed.ncbi.nlm.nih.gov/28331629/ Congenital Diaphragmatic hernia - a review.] Matern Health Neonatol Perinatol. 2017 Mar 11;3:6. doi: 10.1186/s40748-017-0045-1. PMID: 28331629; PMCID: PMC5356475.</ref> There is a distinction between hernias in pre-existing zones of weakness and hernias due to diaphragmatic defects. The first ones normally occur in the '''esophageal hiatus''', '''lumbocostal triangle''' and '''sternocostal triangle'''. Hernias due to diaphragmatic defects can appear mostly in the '''central tendon''' of the [[Diaphragm Anatomy and Differential Diagnosis|diaphragm]] and in the '''costal part''' of the diaphragm. Another anatomical distinction is between '''spurious diaphragmatic hernias''', that do not have a hernia sac, and '''real diaphragmatic hernias,''' that have a hernia sac. Spurious hernias are more frequent than real hernias, that are rare and normally are paraesophageal, for example the congenital esophageal hiatus hernia with the sac. Moreover, there is a clinical differentiation of this condition: '''congenital diaphragmatic hernia''' (CDH) and '''acquired diaphragmatic hernia.'''
Diaphragmatic hernias are defined as either congenital or acquired defects in the diaphragm.<ref>Radiopedia Diaphragmatic Hernia Available:https://radiopaedia.org/articles/diaphragmatic-hernia (accessed 20.12.2022)</ref>


== Congenital Diaphragmatic Hernia (CDH) ==
== Etiology ==
The CDH is a birth disease that occurs when the infant is developing in the womb. The CDH is the most frequent among the diaphragmatic hernias. It has an incidence of about 1 case every 3600 newborns in the United States. It is estimated that half of all newborns who present this condition also have other conditions, including birth defects of the brain, heart, and intestines. However, the causes of diaphragmatic hernia in many cases are still unknown. <ref name=":0">Ahlfeld SK. [https://www.us.elsevierhealth.com/nelson-textbook-of-pediatrics-2-volume-set-9780323529501.html Respiratory tract disorders.] In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:chap 122.</ref>
May be aquired or congenital


A CDH normally occurs when the diaphragm of the infant is not fully developed, therefore, for different reasons, organs of the abdomen are facilitated to move through the hole in the diaphragm and into the baby’s thoracic cavity. The consequences of a CDH are underdeveloped lung tissue and lung blood vessels that can cause insufficient oxygen levels in the body<ref>Mai CT, Isenburg JL, Canfield MA, Meyer RE, Correa A, Alverson CJ, Lupo PJ, Riehle‐Colarusso T, Cho SJ, Aggarwal D, Kirby RS. [https://pubmed.ncbi.nlm.nih.gov/31580536/ National population‐based estimates for major birth defects, 2010–2014]. Birth Defects Research''.'' 2019; 111(18): 1420-1435.</ref>. Therefore, the main symptom is severe breathing difficulty that appears shortly after the birth. Secondary symptoms include: bluish-colored skin, [[tachycardia]] and tachypnea. The two most frequent CDH are a spurious hernia that develops in the lombocostal triangle and a paraoesophageal hernia with hernia sac.
Acquired: usually occur in adulthood:


# Traumatic diaphragmatic rupture through either penetrating injury (65%) or blunt trauma (35%)
# Hiatus hernia
# Iatrogenic
Congenital Diaphragmatic Hernia (CDH):
# CDHs which are uncommon, usually occur on the left side (80%) of the diaphragm. It has an incidence of about 1 case every 3600 newborns in the United States. It is estimated that half of all newborns who present this condition also have other conditions, including birth defects of the brain, heart, and intestines. However, the causes of diaphragmatic hernia in many cases are still unknown. <ref name=":0">Ahlfeld SK. [https://www.us.elsevierhealth.com/nelson-textbook-of-pediatrics-2-volume-set-9780323529501.html Respiratory tract disorders.] In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:chap 122.</ref>
# A CDH normally occurs when the diaphragm of the infant is not fully developed, therefore, for different reasons, organs of the abdomen are facilitated to move through the hole in the diaphragm and into the baby’s thoracic cavity. The consequences of a CDH are underdeveloped lung tissue and lung blood vessels that can cause insufficient oxygen levels in the body<ref>Mai CT, Isenburg JL, Canfield MA, Meyer RE, Correa A, Alverson CJ, Lupo PJ, Riehle‐Colarusso T, Cho SJ, Aggarwal D, Kirby RS. [https://pubmed.ncbi.nlm.nih.gov/31580536/ National population‐based estimates for major birth defects, 2010–2014]. Birth Defects Research''.'' 2019; 111(18): 1420-1435.</ref>. Therefore, the main symptom is severe breathing difficulty that appears shortly after the birth. Secondary symptoms include: bluish-colored skin, [[tachycardia]] and tachypnea. The two most frequent CDH are a spurious hernia that develops in the lombocostal triangle and a paraoesophageal hernia with hernia sac.
# The diagnosis can be done during pregnancy, through a fetal ultrasound exam that shows abdominal organs in the chest cavity. It can be done also through an examination of the newborn, analyzing the regularity of chest movements, breath sounds, presence of bowel sounds in the chest and with a chest x-ray.<ref>Pober BR, Russell MK, Ackerman KG. Congenital Diaphragmatic Hernia Overview. 2006 Feb 1 [Updated 2010 Mar 16]. In: Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2016. Available from: <nowiki>http://www.ncbi.nlm.nih.gov/books/NBK1359/external</nowiki> icon</ref>
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[last accessed 20/05/2022]</ref>
[last accessed 20/05/2022]</ref>
'''Diagnosis'''
The diagnosis can be done during pregnancy, through a fetal ultrasound exam that shows abdominal organs in the chest cavity. It can be done also through an examination of the newborn, analyzing the regularity of chest movements, breath sounds, presence of bowel sounds in the chest and with a chest x-ray.<ref>Pober BR, Russell MK, Ackerman KG. Congenital Diaphragmatic Hernia Overview. 2006 Feb 1 [Updated 2010 Mar 16]. In: Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2016. Available from: <nowiki>http://www.ncbi.nlm.nih.gov/books/NBK1359/external</nowiki> icon</ref>
== Acquired diaphragmatic hernia ==
With acquired diaphragmatic hernias we intend diaphragmatic hernias that affect adults. This is a rare condition with variable clinical manifestation. The majority of acquired diaphragmatic hernias are associated with thoracic and abdominal traumas, with a possible direct injury to the diaphragm.<ref name=":1">Yang GP, Tang CN, Siu WT, Ha JP, Tai YP, Li MK. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015605/#:~:text=Adult%20onset%20diaphragmatic%20hernia%20is,for%20those%20with%20penetrating%20injury. Diaphragmatic hernia: an uncommon cause of dyspepsia]. JSLS. 2005 Jul-Sep;9(3):352-5. PMID: 16121887; PMCID: PMC3015605.</ref>


== Treatment ==
== Treatment ==
The treatment for diaphragmatic hernias is surgical. The aim of the intervention is to replace the abdominal organs into the original position and eventually repair the damaged diaphragm. Traditionally, the surgery is done by '''laparotomy''' or '''thoracotomy'''. <ref name=":1" /> For CDH, the infant can need breathing support for the recovery period, for example with a lung bypass machine that support the oxygen delivery to the body. The prognosis of CDH surgical treatment depends on the level of development of the lungs and on the grade of the damage. <ref name=":0" />
The treatment for diaphragmatic hernias is surgical. The aim of the intervention is to replace the abdominal organs into the original position and eventually repair the damaged diaphragm. Traditionally, the surgery is done by '''laparotomy''' or '''thoracotomy'''. <ref name=":1">Yang GP, Tang CN, Siu WT, Ha JP, Tai YP, Li MK. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015605/#:~:text=Adult%20onset%20diaphragmatic%20hernia%20is,for%20those%20with%20penetrating%20injury. Diaphragmatic hernia: an uncommon cause of dyspepsia]. JSLS. 2005 Jul-Sep;9(3):352-5. PMID: 16121887; PMCID: PMC3015605.</ref> For CDH, the infant can need breathing support for the recovery period, for example with a lung bypass machine that support the oxygen delivery to the body. The prognosis of CDH surgical treatment depends on the level of development of the lungs and on the grade of the damage. <ref name=":0" />


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Revision as of 07:07, 20 December 2022

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Introduction[edit | edit source]

Diaphragmatic hernias are defined as either congenital or acquired defects in the diaphragm.[1]

Etiology[edit | edit source]

May be aquired or congenital

Acquired: usually occur in adulthood:

  1. Traumatic diaphragmatic rupture through either penetrating injury (65%) or blunt trauma (35%)
  2. Hiatus hernia
  3. Iatrogenic

Congenital Diaphragmatic Hernia (CDH):

  1. CDHs which are uncommon, usually occur on the left side (80%) of the diaphragm. It has an incidence of about 1 case every 3600 newborns in the United States. It is estimated that half of all newborns who present this condition also have other conditions, including birth defects of the brain, heart, and intestines. However, the causes of diaphragmatic hernia in many cases are still unknown. [2]
  2. A CDH normally occurs when the diaphragm of the infant is not fully developed, therefore, for different reasons, organs of the abdomen are facilitated to move through the hole in the diaphragm and into the baby’s thoracic cavity. The consequences of a CDH are underdeveloped lung tissue and lung blood vessels that can cause insufficient oxygen levels in the body[3]. Therefore, the main symptom is severe breathing difficulty that appears shortly after the birth. Secondary symptoms include: bluish-colored skin, tachycardia and tachypnea. The two most frequent CDH are a spurious hernia that develops in the lombocostal triangle and a paraoesophageal hernia with hernia sac.
  3. The diagnosis can be done during pregnancy, through a fetal ultrasound exam that shows abdominal organs in the chest cavity. It can be done also through an examination of the newborn, analyzing the regularity of chest movements, breath sounds, presence of bowel sounds in the chest and with a chest x-ray.[4]

[5]

Treatment[edit | edit source]

The treatment for diaphragmatic hernias is surgical. The aim of the intervention is to replace the abdominal organs into the original position and eventually repair the damaged diaphragm. Traditionally, the surgery is done by laparotomy or thoracotomy. [6] For CDH, the infant can need breathing support for the recovery period, for example with a lung bypass machine that support the oxygen delivery to the body. The prognosis of CDH surgical treatment depends on the level of development of the lungs and on the grade of the damage. [2]

[7]

Physiotherapy[edit | edit source]

There is not literature that specifically addresses the physioterapy management of diaphragmatic hernia. However, we know that surgeries such as laparatomy and thoracotomy can affect lung function, causing manifestations such as lung volume reduction, reduction in functional residual capacity, slowing of mucociliary clearance, and abnormalities in gaseous exchange [8]Therefore the physiotherapist can put in place active respiratory techniques and prescribe these exercises according to the assessment and patient's health state. The main techniques of this area of intervention are incentive spirometry, active cycle of breathing, and thoracic expansion exercises.

References[edit | edit source]

  1. ↑ Radiopedia Diaphragmatic Hernia Available:https://radiopaedia.org/articles/diaphragmatic-hernia (accessed 20.12.2022)
  2. ↑ 2.0 2.1 Ahlfeld SK. Respiratory tract disorders. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:chap 122.
  3. ↑ Mai CT, Isenburg JL, Canfield MA, Meyer RE, Correa A, Alverson CJ, Lupo PJ, Riehle‐Colarusso T, Cho SJ, Aggarwal D, Kirby RS. National population‐based estimates for major birth defects, 2010–2014. Birth Defects Research. 2019; 111(18): 1420-1435.
  4. ↑ Pober BR, Russell MK, Ackerman KG. Congenital Diaphragmatic Hernia Overview. 2006 Feb 1 [Updated 2010 Mar 16]. In: Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2016. Available from: http://www.ncbi.nlm.nih.gov/books/NBK1359/external icon
  5. ↑ Children's Hospital Colorado. CDH Part 1: What is Congenital Diaphragmatic Hernia? Available from: https://www.youtube.com/watch?v=LcHdHdCvqnk [last accessed 20/05/2022]
  6. ↑ Yang GP, Tang CN, Siu WT, Ha JP, Tai YP, Li MK. Diaphragmatic hernia: an uncommon cause of dyspepsia. JSLS. 2005 Jul-Sep;9(3):352-5. PMID: 16121887; PMCID: PMC3015605.
  7. ↑ Rocky Mountain Hospital for Children. Minimally Invasive Surgery for Congenital Diaphragmatic Hernia. Available from: https://www.youtube.com/watch?v=J_U7yoHicJU. [last accessed: 20/05/2022]
  8. ↑ Reeve J. Physiotherapy interventions to prevent postoperative pulmonary complications following lung resection. What is the evidence? What is the practice? Physiotherapy. 2008. 36(3):118-130
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