Hernias of the Diaphragm: What causes a hernia in your diaphragm? Can adults have a diaphragmatic hernia?

Normal organs can become malfunctional or diseased when they assume an abnormal position. This can be the problem when abdominal organs get into the chest. This type of hernia produces such varied complaints that it has been called the great masquerader. The symptoms can simulate heart disease, stomach ulcer, or gallbladder ailments. They are often so ill-defined that some patients have been regarded as neurotic until this type of hernia was recognized and corrected.

What is the diaphragm and what does it do?

The diaphragm is a muscle that serves as a bellows fence separating the chest, which contains the heart and lungs, from the abdomen, which contains the intestinal,urinary and generative organs. This separation is complete except for several holes through which various tubular structures pass from above down. These can be likened to firm pipe fittings going through an otherwise intact wall. The diaphragm moves up and down like a bellows, allowing the lung to expand completely. When you take a deep breath, you move the diaphragm down. How do you know that I have a hernia of the diaphragm? The only possible way of making this diagnosis is by an X-ray examination.

What does the X ray show?

It demonstrates that a part of the stomach (and sometimes other organs as well) has gone through the diaphragm into the chest; that is, the organs are now in a different place. Sometimes this can be seen on the ordinary chest X ray, and in other cases it is discovered by the barium swallow GI series.

Who does it come from? How did I get it?

Most adult hernias of the diaphragm come about because of relaxation and widening of the hole through which the swallowing tube (the esophagus) passes to join the stomach. Therefore, most of these hernias contain the upper part of the stomach. Other hernias of the diaphragm are the result of injuries to the diaphragm, often in association with fractured ribs on the left side. The hernia may become apparent only weeks, months or even years after the injury.

Do these hernias also occur in children?

Yes, they may even be seen in newborns. In such instances these hernias are due to birth defects in the development of the diaphragm.

I'm sixty years old and I never knew I had such a hernia. What should I do about it?

Nothing need be done. You can't improve the symptoms of a patient who has no symptoms.

What is the difference between a diaphragmatic hernia and a hiatus hernia?

The terms are often used interchangeably. This is not strictly accurate. While both are hernias of the diaphragm, the hiatal hernia refers specifically to the type that goes through the widened aperture through which the esophagus normally passes. It is by far the commonest hernia of this variety in the adult.

What trouble can this kind of hernia cause?

In the vast majority of patients it is simply diagnosed and there is no problem. However, part of the hernia contents may become inflamed and produce ulcer-type pain, or bleed, or scar so much as to narrow the area and produce swallowing difficulties.

How can you be sure that the symptoms are coming from this since so many produce no trouble at all? 

The X ray is the most important diagnostic aid. The esophagus is easily photographed on a filmstrip, and the movie clearly demonstrates changes in function, position and shape of the involved area.

In all such problems the esophagus can be looked at directly. This examination is done under local anesthesia or under a light sleep. It is not the sort of thing you would have done on a holiday, but there is little discomfort when it is skillfully performed. A hollow tube with a light (esophagoscope) is inserted through the mouth into the esophagus directly to the diseased area. A piece of this tissue is removed for biopsy and microscopic examination. If the area is inflamed, it will be seen microscopically to have certain characteristic changes. This tissue examination also serves conclusively to demonstrate that there is no tumor at that site.

What do you advise for only moderate symptoms?

The treatment of symptomatic hiatal hernia disease is predicated on the observation that the inflammation is due to an alteration in the valvular mechanism at the site where food passes into the upper stomach. This incompetence permits backward drainage of bile and stomach acid into the sensitive lining of the herniated organ. Stomach acid is the usual offender. Medical treatment employs nerve-blocking drugs to reduce acid formation and antacids to neutralize the acid that is present. The recumbent position favors this valvular reflux. Therefore, the patient is advised to sleep in a semisitting position and to avoid reclining shortly after a meal. Frequently an ulcer-type diet has a beneficial effect on the symptoms.

When do you advise operation for this kind of hernia?

An operation should be done when intolerable symptoms are definitely shown to be caused by this hernia and when they are not controllable by diet, medication, and posture. Such severe symptoms are bleeding, leading to anemia, and scarring, resulting in trouble with swallowing.

How effective is the surgery for the alleviation of symptoms?

The results are very satisfactory if the operation is performed properly and if associated ulcer disease in the stomach or gallbladder disease is corrected at the same time.

Is the operation risky?

This is a major operation, but it is not life-threatening in the sense of, say, cardiac surgery for a badly diseased heart.

How will I know if the operation has been successful? If you are cured of your symptoms, then the operation has been successful. That is the most important way of knowing.

What is the operative technique?

There are many ways of fixing this hernia. The basic maneuver is to put the stomach back in its normal position and to hold it there under conditions that are not associated with hyperacidity and regurgitation of acid.

Does this type of hernia fall under the law of compensable injury?

The usual hiatal type does not, but the diaphragmatic hernia that can appear after an injury at work may fall into that category. Each case has to be decided on an individual basis.

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