Human diaphragm disease symptoms. Spasm of the diaphragm and convulsions: causes, symptoms, treatment High value of the diaphragm pathology causes pathogenesis

Diaphragmatic hernia is a displacement of the abdominal organs into the chest cavity, which occurs through the esophageal opening of the diaphragm (therefore, the disease has another name - hiatal hernia). This is a chronic disease with periodic relapses, significantly worsening a person’s quality of life.

Diaphragmatic hernia is a more common condition than it might seem. It occurs in 0.5% of the population, but in half of the patients the clinic does not manifest itself, they do not go to doctors, and the diaphragmatic hernia remains undetected.

Causes

A diaphragmatic hernia is formed due to the stretching of the connective tissue membrane located between the esophagus and the opening of the diaphragm, through which the esophagus passes from the chest cavity to the abdominal cavity.

The reasons why the esophageal opening of the diaphragm increases in size are not fully understood. Factors contributing to membrane weakness and hiatus laxity:

In turn, displacement of the esophagus is observed when:

• digestive tract (disorders of natural muscle contractions);
• pathological conditions of the esophagus itself - scars, tumors, narrowing of the lumen.

The genetic factor is confirmed by the fact that hiatal hernia often occurs in people with other congenital connective tissue disorders - with:

• flat feet;
• Marfan syndrome (such patients are tall, with long limbs and elongated fingers).

The most common factor contributing to membrane weakness is age-related changes in it. Young people may suffer from frequent diseases of the respiratory and digestive organs, accompanied by reflux, but do not suffer from diaphragmatic hernias. On the other hand, the incidence of hiatal hernia increases sharply after 60 years of age - even if such patients were not sick at a younger age or adhered to a proper diet and did not suffer from reflux, vomiting or hiccups.

The immediate cause that most often provokes the occurrence of a diaphragmatic hernia is an increase in intra-abdominal pressure. It is observed in such conditions and processes as:

• strong ;
• frequent and prolonged respiratory diseases, accompanied by frequent coughing attacks;
• chronic diseases of the gastrointestinal tract, accompanied by frequent vomiting;
• loose fluid in the abdomen (ascites);
• huge tumors in the abdominal cavity;
• pregnancy.

The most common cause of increased intra-abdominal pressure is coughing.

Development of the disease

Before passing into the stomach, the esophagus passes into the abdominal cavity through the esophageal opening of the diaphragm, to which it is connected circumferentially by a connective tissue membrane. Thanks to it, a tightness is ensured between the abdominal and thoracic cavities. This membrane is quite elastic - when pressure builds up in the abdominal cavity, it can stretch.

Due to frequent contractions (or congenital insufficiency), the connective tissue elements of the diaphragmatic-esophageal membrane soon wear out and cease to act as a shock absorber - the tightness between the thoracic and abdominal cavities is broken. With subsequent increases in abdominal pressure, the abdominal organs put pressure on the weakened membrane - after a while it is no longer able to hold the abdominal organs, which, with an increase in intra-abdominal pressure, rush into the chest cavity. This is how a hiatal hernia occurs.

The most common types of hernia that develop are:

• sliding– when the area where the esophagus passes into the stomach and a fragment of the stomach itself enters the chest cavity;
• paraesophageal– the esophagogastric junction remains in the abdominal cavity, but part of the stomach penetrates through the esophageal opening and is located above the diaphragm.

A sliding hernia in most cases is determined by chance - it is found in 40% of patients who are performed for some other reason.

Therefore, if a patient has problems with the gallbladder, stomach or intestines, it would be useful for him to be examined for the presence of a hiatal hernia.

Symptoms of diaphragmatic hernia

The most common and characteristic symptoms by which a patient may be suspected of having a hiatal hernia are the following:

• pain;
• signs of backflow of stomach contents into the esophagus.

Pain occurs:

Characteristics of pain with diaphragmatic hernia:

• feels dull;
• the intensity is moderate, patients are able to tolerate it; severe pain is extremely rare;
• most often localized behind the upper third of the sternum;
• may spread along the esophagus;
• in some cases it radiates to the back and between the shoulder blades;
• worsens when trying to bend over.
• In most cases, pain appears:
• after eating (especially large meals);
• during or after physical activity;
• during cough;
• with bloating;
• in a lying position.

It is characteristic that such pain disappears after:

• belching;
• vomiting (sometimes patients artificially induce it for relief);
• deep breath;
• transition to a vertical position;
• taking water or alkaline solutions.

Signs reflux:

Belching – the most common sign of reflux. Its characteristics for diaphragmatic hernia are as follows:

• observed almost immediately after eating;
• can be very pronounced, sonorous;
• during belching, a sour taste is felt in the mouth (due to sour gastric contents), often with a bitter taste (due to an admixture of bile).

Regurgitation with diaphragmatic hernia has the following characteristics:

• most often observed after eating (especially in a lying position);
• in half of the cases it can bother you at night (the so-called “wet night pillow” symptom);
• regurgitation of food is observed, and if repeatedly, after a short time - with sour stomach contents;
• Most often, a small volume of stomach contents is regurgitated - from 10 to 20 ml, but with exacerbation of signs of a diaphragmatic hernia, the volume of regurgitated food can be 2-3 times greater.

Dysphagia develops as a result of obstruction of the esophagus, but this is not a permanent sign of a diaphragmatic hernia. Characteristics of dysphagia:

• the patient complains of an unpleasant pressing feeling behind the sternum during the act of swallowing - often characterizes it as “like a stake”;
• this difficulty in passing food through the esophagus is caused by taking too hot or too cold a liquid, eating in a hurry or in a stressful situation;
• There is a physiological paradox: with dysphagia, solid food passes through the esophagus, although with difficulty, but much easier and faster than liquid or semi-liquid food.

Pain behind the sternum appears only in the presence of reflux.

Heartburn – this is one of the most indicative signs of a diaphragmatic hernia. In some patients, it is the leading sign of diaphragmatic hernia. Characteristics of heartburn with hiatal hernia:

• noted immediately after eating;
• more pronounced if the patient is in a supine position;
• very often occurs at night, even if several hours have passed after eating;
• often subjectively unbearable; patients say that it is easier for them to endure the pain of a hernia than heartburn.

Hiccups observed in a small number of patients with diaphragmatic hernia (according to various sources - from 3 to 7%). But in the absence or scarcity of other symptoms, it may suggest the presence of a hernia. Hiccups are explained by the fact that the hernial protrusion irritates the phrenic nerve, which causes chaotic, uncontrollable contractions of the diaphragm. Characteristics of hiccups in diaphragmatic hernia:

• provoked by food intake;
• manifests itself in the form of protracted attacks lasting several hours, and in severe cases – several days.

Burning and pain in the tongue appear with severe reflux– reflux of acidic stomach contents into the oral cavity, which causes a burn to the mucous membrane of the tongue. Such contents can also enter the larynx, causing hoarseness.

In most cases, diaphragmatic hernias are asymptomatic. First of all, this applies to variants when only a fragment of the stomach penetrates into the chest cavity (paraesophageal hernia). Sliding hernias are clinically more indicative and in some cases are manifested by pain and signs of reflux.

At the same time, complications are more typical for paraesophageal hernias.

Complications of diaphragmatic hernias

In addition to the fact that a diaphragmatic hernia can be detected by chance, it is often diagnosed due to complications. . There are many types of complications of hiatal hernia. The main ones are:

Strangulation is the most difficult and dangerous complication of a hiatal hernia. It occurs when an abdominal organ, having entered through the esophageal opening of the diaphragm, cannot slide back and is compressed in the hernial sac, as well as along the circumference of the sac due to contraction of the connective tissue elements of the membrane between the opening and the esophagus. Signs of infringement:

• increased pain syndrome;
• and multiple with blood;
• disorders of the cardiovascular system - severe, accelerated heartbeat, sharply reduced blood pressure, blue discoloration of the patient’s skin;
• the lower part of the chest seems to bulge, breathing lags behind;
• on the chest organs are shifted to the healthy side.

The most indicative sign of strangulated diaphragmatic hernia is pain. Their characteristics are as follows:

• pain increases sharply and becomes intense;
• the pain is mainly in the area, but can also be felt in the area and radiates to the area between the shoulder blades;
• the nature of the pain is at first similar to contractions, then becomes constant;
• pain is not relieved by eating, drinking water or staying in any position; in rare cases, the pain subsides slightly when the patient is positioned on the left side.

Solarite – This is a lesion of the solar plexus. The plexus itself is a tangle of autonomic nerve fibers, which in many cases are affected secondarily, due to some other diseases - in this case, due to a diaphragmatic hernia. Signs that a diaphragmatic hernia has become complicated by solaritis:

• pain becomes more severe, burning;
• pain intensifies if you press on the solar plexus area;
• Pain relief occurs if the patient takes a knee-elbow position or leans forward.

Bleeding sooner or later complicates the diaphragmatic hernia. About 20% of patients suffer from acute severe bleeding, about 25% suffer from hidden bleeding. The most common cause of bleeding from a hiatal hernia is ulcers and erosions of the esophagus and stomach. The mechanism of such bleeding is as follows:

• the stomach or intestinal loop very often migrates from the abdominal cavity to the chest cavity and back;
• this provokes trauma to the vessels passing in the mucosa and under it;
• after some time, trauma results in a violation of the integrity of the walls of blood vessels, and bleeding begins.

Often, bleeding that complicates a diaphragmatic hernia is caused by vomiting.

Signs of gastrointestinal bleeding with diaphragmatic hernia:

• streaks of blood appear in the vomit;
• stool – dark, semi-liquid;
• deterioration of the patient’s general condition – weakness, apathy, lethargy;
• deterioration of red blood counts.

With hiatal hernias, anemia most often develops not because of acute massive bleeding, but because of constant hidden bleeding. This .

Anemia occurs less frequently due to the fact that, due to constant displacements into the chest cavity, the upper part of the stomach, in which vitamin B12 is produced, atrophies.

You need to pay close attention to sudden anemia in a person who has not previously been ill, since it may be the only sign of a hiatal hernia (remember that such hernias are often asymptomatic). In fact, it is not sudden; its development is preceded by repeated hidden bleeding. Hidden means that there is no visible discharge of blood from the gastrointestinal tract; blood can only change the stool (it becomes semi-liquid and dark, like tar, which is why it is officially referred to as “tar-like feces”).

Manifestations of anemia, which complicates a diaphragmatic hernia, are quite typical for anemia in general - these are:

• general weakness;
• frequent;
• darkening and " ;
• pallor of the skin and visible mucous membranes.

But the fact that this anemia is iron deficiency and indicates a diaphragmatic hernia in the absence of its other symptoms is evidenced by the so-called sideropenia syndrome, which includes:

• dry skin;
• brittleness and spotting of nails due to malnutrition;
• perversion of taste and smell.

Anemia is confirmed by a deterioration in the blood test - low levels:

• red blood cells;
• hemoglobin.

Diagnostics

Since hiatal hernia in most cases is asymptomatic (at least uncomplicated), additional examination methods are important in the early diagnosis of this disease - primarily instrumental:

• with contrast;
• fiberoscopy;
• esophagomanometry.

X-ray using a contrast agent is the most revealing method in diagnosing diaphragmatic hernia.

The patient is given a suspension of barium sulfate to drink, which fills the stomach and esophagus and allows their contours to be determined on an x-ray. In particular, the part of the stomach that has prolapsed into the chest cavity, the shape, size and bends of the esophagus, as well as the location of the esophageal opening of the diaphragm, which appears on an x-ray image as “notches” on the contours of the stomach, will be visible.

X-ray with contrast also allows you to identify and clarify details when a diaphragmatic hernia is pinched - it is determined by a characteristic “bubble” with air.

– examination using a probe, equipped with special optics, which helps to see the gastrointestinal tract from the inside and identify its changes resulting from a diaphragmatic hernia:

• inflammation, erosion, bleeding, ulcers of the esophagus and stomach;
• shortening of the esophagus, which is determined by detecting a decrease in the distance from the patient’s fangs to the stomach (measured using the probe itself).

Due to the formation of a diaphragmatic hernia, an area of ​​increased pressure is determined above the diaphragm, which is measured during esophagomanometry. Decoding the measurement data will help determine the condition of the esophageal opening of the diaphragm.

Laboratory examination methods are not of particular importance in the diagnosis of hiatal hernia. . will help identify anemia and, in the absence of any symptoms, suspect hidden bleeding, which may indicate the presence of a diaphragmatic hernia.

Treatment of diaphragmatic hernia

If a small fragment of the stomach enters the chest cavity without clinical consequences for the patient, no specific treatment is carried out. It is enough to adjust the diet and physical activity so that the patient can avoid uncomfortable sensations, if any, and if they do not exist, prevent the occurrence of such sensations.

If, during repeated instrumental examination, progression of the disease is observed (an increase in the diameter of the esophageal opening of the diaphragm, an increase in the time the abdominal structures remain in the abdominal cavity, the occurrence of complaints), such a hernia should be operated on to avoid the risk of strangulation. The purpose of the operation is to narrow the enlarged esophageal opening of the diaphragm and strengthen it.

In case of a strangulated diaphragmatic hernia, if the symptoms do not decrease or even increase, surgical intervention is performed as an emergency.

Prevention

To prevent the occurrence of a diaphragmatic hernia, the causes of its occurrence and provoking factors should be eliminated - primarily diseases of the respiratory system with frequent coughing, gastrointestinal diseases with vomiting, flatulence, and free fluid in the abdominal cavity. Often, a diaphragmatic hernia regresses after childbirth.

Forecast

With the right medical approach, the prognosis is favorable. Strangulations of a diaphragmatic hernia with all the ensuing consequences (in particular, necrosis of the strangulated contents) occur much less frequently than strangulations with other types of hernias.

Kovtonyuk Oksana Vladimirovna, medical observer, surgeon, consultant doctor

Inflammation of the diaphragm (diaphragmatitis) can be acute and chronic, nonspecific and, much less common, specific.

In mild cases of inflammation of the diaphragm, dilation of blood vessels occurs, then lymphangitis occurs. As inflammatory phenomena increase, swelling of the diaphragm tissue and small cell infiltration appear, individual muscle fibers become homogeneous and disintegrate into fragments. Phlegmonous pandiaphragmatitis develops, sometimes complicated by purulent melting of the diaphragm and the formation of a more or less significant defect.

Symptoms of inflammation of the diaphragm

Secondary lesions of the diaphragm, developing with a subdiaphragmatic abscess, with adjacent abscesses of the liver or lung, recede into the background compared to the main pathology (except for cases with purulent melting of the diaphragm area). Nonspecific diaphragmatitis acquires independent significance in more rare cases, when it occupies the main place in the picture of the disease and manifests itself as a diaphragmatic symptom complex, first identified by M. M. Vicker (1926). The latter consists of the appearance of pain in the area of ​​attachment of the diaphragm to the chest wall, spreading to the abdomen, pain on palpation of these areas and limited or diffuse tension of the abdominal muscles. The appearance of this symptom complex in lower lobe pneumonia and diaphragmatic pleurisy is well known, when it can lead to a diagnosis of acute abdomen. Often this turns out to be a positive phrenicus symptom. One of the differential diagnostic signs of diaphragmatitis is the absence of increased pain during movement.

The development of a diaphragmatic symptom complex usually indicates the presence of a primary inflammatory focus in the vicinity of the diaphragm. It is characteristic that in the first days of inflammation of the diaphragm it is rarely possible to detect auscultatory or percussion changes, which most often appear only on the 3rd day. The dullness of percussion sound that occurs by this time on the affected side depends on the appearance of effusion and an increase in the level of the diaphragm. Auscultatory signs of lower lobe pneumonia also do not appear immediately. Some regard such secondary diaphragmatitis as supradiaphragmatic pleurisy, however, with diaphragmatitis, the first place is a disorder of the diaphragm function.

The surgical significance of acute inflammation of the diaphragm caused by the supradiaphragmatic primary inflammatory focus lies in the need to differentiate it from acute diseases of the abdominal cavity, when emergency surgical intervention is necessary.

With subdiaphragmatic peritonitis or abscess, especially if they are caused by postoperative insufficiency of anastomotic sutures, a subphrenic-pleural or subphrenic-pulmonary (sometimes pericardial) fistula can form. Destruction of the diaphragm with ulcers located above it is observed much less frequently. In the literature there are descriptions of 4 cases of a subdiaphragmatic abscess breaking through the diaphragm into the lung tissue, followed by self-healing. However, such a favorable outcome is an exception; more often patients die from such a terrible complication. Purulent diaphragmatitis with necrosis and the formation of a subphrenic-pulmonary fistula is accompanied by a sudden cough with copious sputum, usually of the same nature as subphrenic exudate, with shortness of breath. When there is a breakthrough in the pleura, there is an acute pain in the side and lower back (with the appearance, as was observed in one of our patients, of Pasternatsky’s symptom), difficulty breathing, and collapse. The pleural cavity in such cases must be drained. If the subphrenic-pulmonary or pleural fistula, sometimes communicating with the lumen of the stomach, becomes chronic, then it is necessary to eliminate it surgically. In this case, great attention should be paid to plastic surgery of the diaphragm using its own tissues (the use of alloplastic prostheses during suppuration is contraindicated!).

Chronic inflammation of the diaphragm

Chronic nonspecific diaphragmatitis (usually a consequence of acute) is manifested by symptoms inherent in the residual effects of pleurisy, and radiographically, by a high standing flattened or deformed diaphragm in the affected area, limitation of its mobility and pronounced pleural overlays and adhesions. Chronic diaphragmatitis can lead to the development of limited relaxation of the diaphragm, contribute to traumatic and sometimes spontaneous rupture.

Specific inflammation of the diaphragm

Of the specific inflammations of the diaphragm, tuberculous diaphragmatitis is most often observed, and only in the form of a very rare pathology are syphilitic and fungal (actinomycosis). Superficial diaphragmatitis develops in almost all patients with tuberculous pleurisy. The muscle layer of the diaphragm can be affected in miliary tuberculosis. With actinomycosis, the diaphragm is affected secondarily by the lungs, stomach or splenic angle of the large intestine. Gummous lesions of the diaphragm can be primary or secondary.

The diaphragm (synonymous with the thoraco-abdominal barrier) is a muscular aponeurotic plate that separates the chest cavity from the abdominal cavity; has the shape of a dome, convexly facing upward (Fig.). The muscular part of the diaphragm starts from the sternum, lower (VII - XII) ribs and lumbar vertebrae. The muscle bundles converge radially towards the middle and end at the tendon center. The inferior vena cava passes through the opening in the tendon center of the diaphragm, and the aorta and thoracic lymphatic duct and vagus nerves pass through the openings in the muscular section. Through separate slits on each side of the diaphragm pass the sympathetic nerve trunks, the celiac nerve, the azygos vein on the right and the semi-gypsy vein on the left. The diaphragm is covered above by the pleura and pericardium, and below by the peritoneum. The height of the diaphragm is variable. On average, in an adult, the highest point of the right dome of the diaphragm is on the horizontal, passing through the place of attachment of the IV costal cartilage to the sternum, the left one is one rib lower. The blood supply to the diaphragm is carried out by the superior and inferior phrenic, as well as the muscular and pericardiophrenic arteries. They are accompanied by veins of the same name. The diaphragm is innervated by the phrenic nerve.

Diaphragm (bottom): 1 - sternal part;
2 - esophageal opening; 3 - costal part; 4 - lumbocostal triangle; 5 - aortic opening; b - medial leg; 7 - lumbar part; 8 - opening of the inferior vena cava; 9 - tendon center.

Rice. 1. Diaphragm from the abdominal cavity: 1 and 18 - m. psoas major; 2 - v. azygos; 3 - eras lat. (BNA); 4 - eras intermed. (BNA); 5 - cras med. (BNA); 6 - n. spianchnicus major; 7 - a. phrenica dext.; S-vv. phrenicae dext.; 9 - v. cava inf.; 10 - vv. phrenicae sin.; 11 - centrum tendineum; 12 - oesophagus; 13 - a. phrenica sin.; 14 - glandula suprarenalis sin.; 15 - aorta; 16 - ren sin.; 17 - v. hemiazygos.


Rice. 2. Diaphragm from the chest cavity: 1 - aorta; 2 and 15 -aa. pericardiacophrenicae sin. et dext.; 3 and 13-nn. phrenici sin. et dext.; 4 and 14 - vv. pericardiacophrenicae sin. et dext.; 5 - diaphragmatic part of the pericardium; 6 and 12 -vv. musculophrenicae sin. et dext.; 7 and 11 - a. musculophrenica; 8 - oesophagus; 9 - sternum; 10 - v. cava inf.

The main physiological function of the diaphragm is breathing. The rhythmic contractions of the diaphragm during breathing are based on reflex mechanisms (see Breathing). Impulses coming through the phrenic nerves lead to contraction and flattening of the diaphragm, resulting in inhalation.

Closed injuries to the diaphragm occur when the chest is compressed or struck by blunt objects. Open injuries, often stab wounds, are localized in the posterolateral sections of the diaphragm; in wartime, damage to the diaphragm most often occurs due to gunshot injuries to the chest wall or abdomen. Damage to the diaphragm is often combined with trauma to the organs of the chest and abdominal cavities, and may be accompanied by prolapse of abdominal organs (stomach, colon, spleen, etc.) into the pleural cavity, and with a gaping wound of the chest wall - outward (see). Symptoms of damage to the diaphragm: pain in the abdomen and chest, radiating to, frequent; Damage to the diaphragm is often accompanied by shock. An undoubted sign of damage to the diaphragm is the detection of abdominal organs in the chest cavity (during an X-ray examination), their loss from the wound of the chest wall or the leakage of the contents of the abdominal organs from it.

First aid: if there is a wound to the abdominal or chest wall, clean it and apply a dry aseptic bandage. If the abdominal organs fall out of the wound of the chest wall, they are not reduced, limiting themselves to the application of an aseptic dressing. The patient is injected subcutaneously with cardiac medications (camphor,) and is allowed to inhale humidified oxygen. Drugs are prohibited as they can obscure the clinical picture of the injury. The patient is immediately transported (in a prone position) to a medical facility.

Treatment in a surgical hospital: surgery with anti-shock measures, starting with a vago-sympathetic cervical blockade (see Novocaine blockade). The wound of the chest wall is widened, the prolapsed organs are brought down into the abdominal cavity and sutures are placed on the diaphragm, after which a laparotomy is performed (revision of the abdominal organs and necessary interventions).

Diaphragmatic hernia occur with pathological expansion of natural openings in the places where the aorta, esophagus, and inferior vena cava pass through the diaphragm (congenital hernias). More often, the formation of hernias is facilitated by former wounds of the diaphragm (traumatic hernias). Symptoms of a diaphragmatic hernia: chest pain, belching and due to movement of the stomach into the chest cavity, shortness of breath, and cyanosis due to compression of the lungs, displacement of the heart and limited movement of the diaphragm. Hiatal hernias can become strangulated, causing symptoms of intestinal obstruction (see Intestinal Obstruction). It is important in diagnosing diaphragmatic hernias. Treatment for traumatic diaphragmatic hernia is surgical; In case of a congenital hernia, the question of surgery is decided individually.

Tumors of the diaphragm most often they are secondary due to their spread from neighboring organs (liver, stomach).

Inflammation of the diaphragm As a rule, it occurs when the process spreads from the subphrenic space (see) or from the chest cavity (with purulent diseases of the lungs and pericardium).

Lecture topic: Diseases of the diaphragm.

The purpose of the lecture: training, education.

Relevance: Among various pathological processes affecting the organs of the thoracic and abdominal cavities, diseases of the diaphragm occupy a special place, primarily due to anatomical and physiological characteristics, as well as the extraordinary complexity of their clinical diagnosis.

The anatomical position of the diaphragm is the undoubted reason for its complete inaccessibility to study by general surgical clinical methods (palpation, percussion, auscultation).

In this regard, pathological processes of the diaphragm remained inaccessible for clinical diagnosis for a long time, and diseases of the diaphragm were considered rare. However, it is known that there are no rare diseases, but only rare diagnoses, which indicates that practicing doctors are insufficiently familiar with a particular disease and is the cause of serious diagnostic and treatment errors.

Materials:

General view of the diaphragm from below
1-tendon center; 2-lumbar part of the diaphragm; 3-rib part; 4-breasted part; 5-sternocostal triangle; 6-lumbocostal triangle; 7-aorta; 8-esophagus; 9-inferior vena cava.

DIAPHRAGM DEVELOPMENTAL DISORDERS

1. 
   Partial defects:
   1) posterolateral
   2) anterolateral
   3) central
   4) esophageal-aortic
   5) phrenopericardial
2. 
   Bilateral aplasia
3. 
   Unilateral aplasia
   Scheme of localization of partial congenital defects of the diaphragm.
   1-posterolateral defect; 2-anterolateral defect; 3-central; 4-esophageal-aortic; 5-phrenopericardial; 6-sided aplasia of the diaphragm.

Classification of hiatal hernias

I. Sliding hiatal hernia

Without shortening of the esophagus

1. 
   Cardiac
2. 
   Cardiofundal
3. 
   Subtotal gastric
4. 
   Total gastric

1. 
   Cardiac
2. 
   Cardiofundal
3. 
   Subtotal gastric
4. 
   Total gastric

1. 
   Fundal
2. 
   Antral
3. 
   Intestinal
4. 
   Gastrointestinal
5. 
   Omental

Causes of hiatal hernia:

Predisposing factors:

1. 
   Expansion of the esophageal opening of the diaphragm due to atrophy of the muscle fibers of the medial crus of the diaphragm;
2. 
   Stretching of the esophageal-phrenic membrane;
3. 
   Shortening of the esophagus (spastic or cicatricial);
4. 
   Constitutional characteristics of the body, weakness of connective tissue.
5. 
   Surgical interventions on the cardia, diaphragm; Gastric resection changes the His angle.

1. 
   Obesity, ascites, pregnancy, large abdominal tumors;
2. 
   Cough, constipation, flatulence, frequent repeated vomiting.

1. 
   PAIN
2. 
   HEARTBURN
3. 
   DYSPHAGIA
4. 
   RETURNING
5. 
   REFLECTIVE ANGINA
6. 
   VOMIT
7. 
   SCAR STENOSIS
8. 
   REPEATED STOMACH BLEEDINGS
9. 
   CHRONIC HYPOCHROMIC ANEMIA

1. 
   X-ray methods.
2. 
   Esophageal pH-metry.
3. 
   Esophagoscopy (“gaping cardia”, hyperemia, edema, hemorrhages, fibrin, ulcers, erosions).
4. 
   Esophagomanometry - the area of ​​increased pressure will be above the hernial orifice.

1. 
   bleeding;
2. 
   perforation of esophageal ulcers;
3. 
   aspiration pneumonia;
4. 
   cicatricial stenosis of the lower third of the esophagus;
5. 
   partial or complete infringement.

1. 
   Elimination of factors that increase intra-abdominal pressure:
   • 
     Obesity
   • 
     Binge eating
   • 
     Constipation
   • 
     Working in an inclined position
   • 
     Pregnancy, ascites

4. Anti-ulcer diet.

Surgical treatment of hiatal hernia

Operation stages:

1. 
   Reduction of the stomach from the mediastinum into the abdominal cavity;
2. 
   Mobilization of the esophagus, cardia and fundus of the stomach;
3. 
   Narrowing of the hernial orifice – crurorrhaphy;
4. 
   Fundoplication - wrapping the esophagus with the fundus of the stomach according to Nissen (thus creating a valve that prevents reflux);
5. 
   Esophagophundoraphy - suturing the fundus of the stomach to the esophagus

Cutting off an inside-out hernial sac

Applying U-shaped sutures to the hernial orifice

Transabdominal fundoplication with mediastinalization of the cardia:

Fixation of the stomach to the edges of the dilated hernial orifice

Transpleural fundoplication for sliding hernia with shortening of the esophagus

Performing a Nissen fundoplication

The auxiliary hole in the diaphragm is sutured, the stomach is sutured to the edges of the hernial orifice

DIAPHRAGM RELAXATION

DIAPHRAGM RELAXATION – relaxation or drop in tone of the diaphragm due to underdevelopment or absence of the diaphragm muscle.

CLINICAL FORMS

1. 
   Asymptomatic;
2. 
   With erased clinical signs;
3. 
   With pronounced clinical signs;
4. 
   Complicated (acute gastric volvulus, gastric bleeding, gastric ulcer).

1. 
   respiratory;
2. 
   cardiovascular;
3. 
   gastrointestinal.

Physical examinations reveal:

1. 
   Increasing Traube space.
2. 
   Shift upward of the lower border of the left lung.
3. 
   Absence or weakening of breathing sounds in this area.
4. 
   Detection of bowel sounds, rumbling and splashing sounds over the chest.
5. 
   Displacement of cardiac dullness.
6. 
   Decrease in vital capacity and Stange test. The X-ray method of examination is of decisive importance.

Emergency surgery is indicated:

In case of RD complicated by diaphragm rupture,

In case of RD complicated by acute gastric volvulus,

For RD complicated by gastric bleeding,

In case of RD complicated by asphyxia in newborns.

Plastic surgery for relaxation of the diaphragm

Sewing the base of the fold of the relaxed diaphragm with U-shaped seams

The fold of the relaxed diaphragm is sutured to the preserved muscles of the diaphragm

Dissection of the relaxed portion of the diaphragm dome

Sewing the edges of the dissected dome of the diaphragm

Means: multimedia equipment, codegrams, demonstration of patients.

1. 
   Surgical diseases of the abdominal organs. Gastroenterological module: educational method. manual for 5th year medical students, pediatrician. and medical prevention. fak. / ed. S. V. Ivanova; State Educational Institution of Higher Professional Education KSMU Federal. health and social agencies Development, Department surgeon. diseases No. 1. – Kursk: KSMU, 2006. – 103 p.: ill.
2. 
   Vasilenko V.Kh., Grebnev A.L. Hiatal hernia. – M., Medicine. – 1978
3. 
   Petrovsky B.V., Kanshin N.N., Nikolaev N.O. Diaphragm surgery. – M., Medicine, - 1982

Diaphragmatic hernia(DH) account for 2% of all types of hernias. This disease occurs in 5-7% of patients with gastric complaints during X-ray examination.

The first description of DG belongs to Ambroise Paré (1579). A diaphragmatic hernia should be understood as the penetration of internal organs through a defect in the diaphragm from one cavity to another.

It should be recalled that the development of the diaphragm occurs due to the connection on both sides of the pleuroperitoneal membrane, the transverse septum and the mesoesophagus.

Disturbances that occur during complicated embryonic development can lead to a partial or complete diaphragm defect in the newborn. When developmental disorders occur before the formation of the diaphragm membrane, then the hernia does not have a hernial sac (it is more correct to talk about eventration). At later stages of development, when a membranous diaphragm has already formed and the development of the muscular part is only delayed, a hernial sac consisting of two serous films penetrates through the hernial orifice, which does not contain muscle.

The place of penetration of sternocostal hernias (sternocostal) is the muscleless area of ​​​​the connection with the sternum and costal part. This place is called Larrey's sternocostal triangle, and such hernias are called Larrey's triangle hernias. In the absence of serous cover, there is a sternocostal foramen of Morgagni.

Due to the anatomical features of the location of the anterior and posterior muscles within the lumbocostal triangle of Bochdalek, a hernial protrusion may occur in this place.

Classification of diaphragmatic hernias according to B.V. Petrovsky:

I. traumatic hernias:

• true;
• false.

II. Non-traumatic:

• false congenital hernias;
• true hernias of weak areas of the diaphragm;
• true hernias of atypical localization;
• hernia of the natural openings of the diaphragm:

a) esophageal opening;
b) rare hernias of the natural openings of the diaphragm.

Traumatic hernias due to wounds are mostly false, closed injuries - true and false.

In case of non-traumatic hernias, the only false one is a congenital hernia - a defect of the diaphragm, due to non-closure between the thoracic and abdominal cavities.

Among the weak areas of the diaphragm are hernias in the area of ​​the sternocostal triangle (Bogdalek’s gap). The chest in these areas is separated from the abdominal cavity by a thin connective tissue plate between the pleura and peritoneum.

The area of ​​underdeveloped sternal part of the diaphragm is a retrosternal hernia.

Rare (extremely) hernias of the sympathetic nerve fissure, vena cava, aorta. In terms of frequency, hiatal hernia (HH) is in first place; they account for 98% of all diaphragmatic hernias of non-traumatic origin.

Hiatal hernia

Anatomical features. The esophagus passes from the thoracic cavity to the abdominal cavity through the hiatus oesophagcus, formed from the muscles that make up the diaphragm. The muscle fibers that form the right and left legs of the diaphragm also form the anterior loop, which in most cases is formed from the right leg. Behind the esophagus, the legs of the diaphragm do not connect intimately, forming a Y-shaped defect. Normally, the esophageal opening has a fairly wide diameter, approximately 2.6 cm, through which food passes freely. The esophagus goes obliquely through this opening, above the opening it lies in front of the aorta, below the opening somewhat to the left of it.

11 variants of muscle anatomy in the area of ​​the esophageal opening are described. In 50% of cases, the esophageal opening is formed from the right leg of the diaphragm, in 40% there are inclusions of muscle fibers from the left leg. Both diaphragmatic legs begin from the lateral surfaces of the I-IV lumbar vertebrae. The esophageal ring contracts slightly during inhalation, resulting in an increase in the curvature of the esophagus at the hiatus. The abdominal segment of the esophagus is small, its length is variable, on average about 2 cm.

The esophagus enters the stomach at an acute angle. The fundus of the stomach is located above and to the left of the esophagogastric junction, occupying almost the entire space under the left dome of the diaphragm. The acute angle between the left edge of the abdominal esophagus and the medial edge of the fundus of the stomach is called the angle of His. The folds of the mucous membrane of the esophagus, descending into the lumen of the stomach from the top of the angle (Gubarev valve), play the role of an additional valve. When the pressure in the stomach rises, especially in the area of ​​its bottom, the left half of the semi-ring of the esophageal-gastric junction shifts to the right, blocking the entrance to the esophagus. The cardiac part of the stomach at the junction with the esophagus is a narrow ring about 1 cm in diameter. The structure of this section is very similar to the structure of the pyloric section of the stomach. The submucosa is loose, parietal and chief cells are absent. By eye you can see the junction of the mucous membrane of the esophagus with the mucous membrane of the stomach. The junction of the mucous membranes is located next to the anastomosis, but does not necessarily correspond to it.

There is no anatomically defined valve in this area. The lower part of the esophagus and the esophagogastric junction are held in the esophagus by the phrenoesophageal ligament. It consists of leaves of the transversus abdominis fascia and intrathoracic fascia. The phrenic-esophageal ligament is attached around the circumference of the esophagus in its diaphragmatic part. The attachment of the ligament occurs over a fairly wide area - from 3 to 5 cm in length. The upper layer of the phrenoesophageal ligament is usually attached 3 centimeters above the junction of the squamous epithelium and the columnar epithelium. The lower leaf of the ligament is 1.6 centimeters below this connection. The membrane is attached to the wall of the esophagus through the thinnest trabecular bridges connecting to the muscular lining of the esophagus. This attachment allows for dynamic interaction between the esophagus and the diaphragm during swallowing and breathing as the abdominal esophagus lengthens or contracts.

Closing mechanism of the esophagus. There is no anatomically defined sphincter in the cardiac region. It has been established that the diaphragm and its legs do not participate in the closure of the cardia. Reflux of gastric contents into the esophagus is undesirable because the epithelium of the esophagus is extremely sensitive to the digestive action of acidic gastric juice. Normally, pressure would seem to predispose to its occurrence, since in the stomach it is higher than atmospheric pressure, and in the esophagus it is lower. For the first time, the work of Code and Ingeifinger proved that in the lower segment of the esophagus, 2-3 centimeters above the level of the diaphragm, there is a zone of increased pressure. When measuring pressure with a balloon, it was shown that the pressure in this zone is always higher than in the stomach and in the upper parts of the esophagus, regardless of body position and the respiratory cycle. This department has a pronounced motor function, which is convincingly proven by physiological pharmacological and radiological studies. This part of the esophagus acts as an esophagogastric sphincter; closure occurs completely over the entire area, and not in the form of contraction of individual segments. When the peristaltic wave approaches, it completely relaxes.

There are several options for hiatal hernias. B.V. Petrovsky proposed the following classification.

I. Sliding (axial) hiatal hernia

Without shortening of the esophagus With shortening of the esophagus

1. Cardiac
2. Cardiofundal
3. Subtotal gastric
4. Total gastric

Paraesophageal hernias

1. Fundal
2. Antral
3. Intestinal
4. Gastrointestinal
5. Omental

It is necessary to distinguish :

1. Congenital “short esophagus” with intrathoracic location of the stomach;
2. Paraesophageal hernia, when part of the stomach is inserted on the side of the normally located esophagus;
3. Sliding GPO, when the esophagus, together with the cardiac part of the stomach, is retracted into the chest cavity.

A sliding hernia is so called because the postero-superior part of the cardiac part of the stomach is not covered by the peritoneum and, when the hernia is displaced into the mediastinum, it slides out like a bladder or cecum in an inguinal hernia. In a paraesophageal hernia, an organ or part of an abdominal organ passes into the esophageal hiatus to the left of the esophagus, and the cardia of the stomach remains fixed in place. Paraesophageal hernias, like sliding ones, can be congenital and acquired, but congenital hernias are much less common than acquired ones. Acquired hernias are more common over the age of 40 years. Age-related tissue involution is important, which leads to expansion of the esophageal opening of the diaphragm and weakening of the connection between the esophagus and the diaphragm.

The immediate causes of hernia formation can be two factors. Ripple factor - increased intra-abdominal pressure during heavy physical activity, overeating, flatulence, pregnancy, and constant wearing of tight belts. Traction factor - hypermotility of the esophagus associated with frequent vomiting, as well as a violation of the nervous regulation of motility.

Paraesophageal hernia

The hernia defect is located to the left of the esophagus and can be of various sizes - up to 10 centimeters in diameter. Part of the stomach prolapses into the hernial sac, lined with fibrously modified diaphragmatic peritoneum. The stomach seems to be wrapped in a defect in relation to the esophageal-gastric junction fixed in the opening. The degree of inversion may vary.

Clinic. Clinical symptoms of paraesophageal hernia are caused mainly by the accumulation of food in the stomach, partially located in the chest cavity. Patients feel pressing pain in the chest, especially intense after eating. First they avoid eating in large quantities, then in regular doses. There is weight loss. Symptoms characteristic of esophagitis occur only when a paraesophageal hernia is combined with a sliding one.

When a hernia is strangulated, progressive stretching of the prolapsed part of the stomach occurs until it ruptures. Mediastinitis develops rapidly with severe pain, signs of sepsis and fluid accumulation in the left pleural cavity. A hernia can cause the development of peptic ulcers of the stomach, since the passage of food from the deformed stomach is impaired. These ulcers are difficult to treat and are often complicated by bleeding or perforation. The diagnosis is made mainly by X-ray examination if a gas bubble is detected in the chest cavity. A barium test confirms the diagnosis.

In order to find out the type of hernia, it is very important to determine the location of the esophagogastric anastomosis. Esophagoscopy can be used to diagnose concomitant esophagitis.

Clinic. The most typical signs are: pain in the epigastric region after eating, belching, vomiting. If the stomach remains in the hernial opening of the diaphragm for a long time, dilatation of the veins of the distal esophagus and cardia may occur, manifested by bloody vomiting.

Treatment. Conservative therapy consists of a special diet. Food should be taken often and in small portions. The diet is generally similar to the anti-ulcer diet. After eating, it is recommended to take walks and never lie down. To prevent possible complications - pinching and rupture of the wall, surgical treatment is indicated. The optimal access is transabdominal. By gentle traction, the stomach is lowered into the abdominal cavity. The hernial orifice is sutured with additional suturing of the angle of His or esophagofundoplication. Relapses are rare. After surgery, clinical symptoms decrease and nutrition improves.

sliding hernia

The cause of this hernia is the pathology of the phrenoesophageal ligament, which fixes the esophagogastric anastomosis inside the esophageal opening of the diaphragm. Part of the cardiac part of the stomach moves upward into the chest cavity. The phrenoesophaeal ligament becomes thinner and lengthens. The esophageal opening in the diaphragm expands. Depending on the position of the body and the filling of the stomach, the esophagogastric anastomosis shifts from the abdominal cavity to the thoracic cavity and vice versa. When the cardia shifts upward, the angle of His becomes obtuse, and the folds of the mucous membrane are smoothed out. The diaphragmatic peritoneum shifts along with the cardia; a well-defined hernial sac occurs only with large hernias. Fixation and narrowing by scars can lead to shortening of the esophagus and the permanent location of the esophagogastric junction above the diaphragm. In advanced cases, fibrous stenosis occurs. Sliding hernias are never strangulated. If there is compression of the cardia displaced into the chest cavity, then circulatory disturbance does not occur, since the outflow of venous blood occurs through the esophageal veins, and the contents can be emptied through the esophagus. A sliding hernia is often combined with reflux esophagitis.

An upward displacement of the cardiac region leads to a flattening of the His angle, the activity of the sphincter is disrupted, and the possibility of gastroesophageal reflux is created. However, these changes are not natural, and in a significant number of patients, reflux esophagitis does not develop, since the physiological function of the sphincter is preserved. Therefore, displacement of the cardia alone is not enough for sphincter insufficiency to develop; in addition, reflux can be observed without a sliding hernia. An unfavorable relationship between the pressure in the stomach and in the esophagus contributes to the penetration of gastric contents into the esophagus. The epithelium of the esophagus is very sensitive to the action of gastric and duodenal contents. Alkaline esophagitis due to the influence of duodenal juice is even more severe than peptic esophagitis. Esophagitis can become erosive and even ulcerative. Constant inflammatory swelling of the mucous membrane contributes to its easy trauma with hemorrhages and bleeding, which sometimes manifests itself in the form of anemia. Subsequent scarring leads to the formation of a stricture and even complete closure of the lumen. Most often, reflux esophagitis accompanies a cardiac hernia, less often a cardiofundal hernia.

Clinic. Sliding hernias without complications are not accompanied by clinical symptoms. Symptoms occur when gastroesophageal reflux and reflux esophagitis are associated. Patients may complain of heartburn, belching, and regurgitation. The appearance of these symptoms is usually associated with a change in body position; the pain intensifies after eating. The most common symptom is a burning sensation behind the sternum, observed in 90% of patients. The pain can be localized in the epigastric region, left hypochondrium and even in the heart area. They are not similar to ulcers, since they appear immediately after eating, are associated with the amount of food taken, and are especially painful after a heavy meal. Relief occurs after taking medications that reduce stomach acidity. Regurgitation occurs in half of the cases, especially after eating a large meal; bitterness is often felt in the larynx. Dysphagia is a late symptom and is observed in 10% of cases. It develops due to spasms of the inflamed distal end of the esophagus. Dysphagia occurs periodically and disappears periodically. As inflammatory changes progress, dysphagia occurs more frequently and may become permanent.

Bleeding may occur from the resulting ulcerations of the esophagus, which proceeds hidden.

Kasten syndrome– a combination of hiatal hernia, chronic cholecystitis and duodenal ulcer.

Diagnostics difficult. Patients are most often interpreted as suffering from peptic ulcer, cholecystitis, angina pectoris or pleurisy. There are known cases of erroneous puncture of the pleural cavity and puncture or even drainage of a hollow organ (in our practice, we observed how a drainage tube was installed twice in the fundus of the stomach) due to the suspicion of exudative pleurisy.

Triad Senta: hiatal hernia, cholelithiasis, colon diverticulosis.

Diagnosis is difficult. Patients are often interpreted as suffering from cholelithiasis or chronic colitis. It is detected more often during surgery for acute calculous cholecystitis or acute intestinal obstruction when the colon is strangulated in a hernia.

An X-ray may help. But it helped us make the correct diagnosis and choose the optimal tactics for a patient admitted with acute destructive cholecystitis. The patient underwent cholecystectomy, elimination of the irreducible hiatal hernia with resection of the transverse colon and descending colon, suturing of the hernial orifice with Nissen esophagofundoplication.

Decisive role X-ray examination plays a role in making a diagnosis. In the diagnosis of hiatal hernia, the main diagnostic method is x-ray. Quincke position (legs above head). Direct symptoms of hiatal hernia include swelling of the cardia and vault of the stomach, increased mobility of the abdominal esophagus, flatness and absence of the His angle, antiperistaltic movements of the esophagus (“dance of the pharynx”), and prolapse of the esophageal mucosa into the stomach. Hernias up to 3 cm in diameter are regarded as small, from 3 to 8 - as medium and more than 8 cm - as large.

In second place in terms of information content they are worth endoscopic methods , which, in combination with x-ray studies, make it possible to increase the detection rate of this disease to 98.5%. Characteristic: 1) decreasing the distance from the anterior incisors to the cardia; 2) the presence of a hernial cavity; 3) the presence of a “second entrance” to the stomach; 4) gaping or incomplete closure of the cardia; 5) transcardial migrations of the mucous membrane; 6) gastroesophageal reflux; 7) signs of hernial gastritis and reflux esophagitis (RE); 8) the presence of a contractile ring; 9) the presence of foci of epithelial ectomy – “Barrett’s esophagus”.

Intraesophageal pH-metry can detect EC in 89% of patients. Manometric method for determining the condition of the LES. For paraesophageal hernias, diagnostic thoracoscopy is recommended.

Laboratory research plays a supporting role. A significant number of patients with hiatal hernia and esophagitis also suffer from duodenal ulcers or gastric hypersecretion, characteristic of peptic ulcer disease. The more severe the esophagitis and the disorders caused by it, the more often patients have a concomitant duodenal ulcer. In order to clarify the diagnosis in doubtful cases, the Bernstein test is performed. A gastric tube is inserted into the lower end of the esophagus and a 0.1% solution of hydrochloric acid is poured through it so that the patient cannot see it. The administration of hydrochloric acid causes symptoms of esophagitis in the patient.

Treatment. Conservative treatment for sliding hernia with esophagitis usually does not bring much success. It is necessary to exclude tobacco, coffee, and alcohol. Food should be taken in small portions and should contain a minimum amount of fat that remains in the stomach for a long time. Raising the head of the bed reduces the possibility of reflux. Drug antiulcer therapy is advisable, although its effectiveness is low. Antiseptics are contraindicated because they increase gastric congestion. Indications for surgery are: ineffectiveness of conservative therapy and complications (esophagitis, obstruction of the esophagus, severe deformation of the stomach, etc.).

There are many surgical methods for treating hiatal hernia. There are basically two requirements for them: 1) reposition and retention of the esophageal-gastric junction under the diaphragm; 2) restoration of a constant acute cardiofundal angle.

An interesting operation is the antelateral movement of the POD with suturing of the hernial orifice tightly.

R. Belsey in 1955 first reported transthoracic esophagofundoplication followed by fixation to the diaphragm with V-shaped sutures. Relapse in 12% of cases. Many surgeons usually sutured the stomach to the anterior abdominal wall. In 1960 L. Hill developed the posterior gastropexy procedure with cardia calibration. Some surgeons use esophagophundoraphy (suturing the fundus of the stomach with the terminal esophagus) to restore the valvular function of the cardia.

Transperitoneal access is preferable for uncomplicated hernias. If the hernia is combined with shortening of the esophagus due to stenosis, it is better to use transthoracic. Transabdominal access also deserves attention because some patients with eeophagitis have lesions of the bile ducts that require surgical correction. Approximately 1/3 of patients with esophagitis suffer from a duodenal ulcer, so it is advisable to combine the removal of a hernia with vagotomy and pyloroplasty.

A common surgical treatment is the Nissen procedure combined with angle closure. In 1963, Nissen proposed fundoplication for the treatment of hiatal hernia complicated by esophagitis. In this operation, the fundus of the stomach is wrapped around the abdominal esophagus, and the edges of the stomach are sutured together with the wall of the esophagus. If the esophageal opening is particularly wide, the legs of the diaphragm are sutured. This operation prevents cardioesophageal reflux well and does not interfere with the passage of food from the esophagus. Nissen fundoplication is equally good for treating a hernia and preventing reflux.

Relapses of the disease are rare, especially in unadvanced cases. Restoring anatomical relationships with a sliding hernia leads to a cure for reflux esophagitis. For hernias combined with shortening of the esophagus due to esophagitis, the best results are obtained by the operation of B.V. Petrovsky. After fundoplication, the diaphragm is dissected in front, the stomach is sutured with separate sutures to the diaphragm and remains fixed in the mediastinum (mediastinolization of the cardia).

After this operation, reflux disappears due to the presence of a valve and the stomach does not become pinched, since the hole in the diaphragm becomes wide enough. Fixation to the diaphragm prevents its further displacement into the mediastinum. Nissen, when the cardia is located in the mediastinum above 4 cm above the level of the diaphragm, recommends using fundoplication using a transpleural approach in such patients, leaving the upper part of the cardia in the pleural cavity. B.V. Petrovsky in these cases uses valve gastropplication, which can be performed transabdominally, which is very important for elderly patients.

Traumatic diaphragmatic hernia . Particular distinction should be made between diaphragmatic-intercostal hernias, when the diaphragm ruptures at the site of attachment of its fibers to the lower ribs or in the area of ​​the sealed pleural sinus. In these cases, the hernial protrusion does not fall into the free pleural cavity, but into one of the intercostal spaces, usually on the left.

Clinical picture. There are symptoms of acute organ displacement that occurs after injury and chronic diaphragmatic hernia.

Characteristic:

1. respiratory and cardiac disorders;
2. symptoms of abdominal problems (vomiting, constipation, bloating)

Complications. Irreducibility and infringement (30-40% of all DHs). Hernias after injuries are more prone to strangulation.

Factors contributing to infringement: small size of the defect, rigidity of the ring, heavy food intake, physical stress. The clinical picture of strangulation corresponds to the clinical picture of intestinal obstruction. If the stomach is strangulated, it is not possible to install a gastric tube.

Differential diagnosis between DG and diaphragm relaxation. Pneumoperitoneum.

Surgical treatment. Transpleural or transabdominal approaches.