Diaphragmatic hernia

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Top Contributors - Lucinda hampton and Blanca Fernandez Burgos  

Anatomy and classifications

Diaphragmatic hernias are protrusions of abdominal organs such as small intestine, stomach, spleen, and part of the liver in the thoracic cavity. 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 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.

Congenital Diaphragmatic Hernia (CDH)

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.

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. 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.

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.

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.

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. 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.

Physiotherapy

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 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.