Hiatal Hernia, CDH and Eventration of diaphragm😍

Hiatal Hernia

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  • Retrocardiac opacity containing air fluid level.

Types

  • Type I/Sliding Hiatal Hernia:
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    • M/C diaphragmatic hernia 
      • (Note: m/c congenital diaphragmatic hernia: Bochdalek)
    • GE junction moves proximally.
    • GERD/Asymptomatic (Not life threatening).
    • IOC: CT with oral contrast.
    • Mx: Surgery only in large/symptomatic hernia.
  • Type II/Rolling/Paraesophageal Hiatal Hernia:
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    • Portion of stomach herniates into thoracic cavity → volvulus & necrosis
    • Life threatening
    • GE junction: N.
    • Mx: Surgery.
  • Type III: Sliding + Rolling.
    • Mx: Based on rolling component.
  • Type IV: Paraesophageal
    • Content: Not stomach

Congenital Diaphragmatic Hernia

  • Absence of the pleuroperitoneal membrane.
  • Leads to persistence of the pleuroperitoneal canal (Bochdalek foramen)
  • M/c → Left > right
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  • Clinical Features:
    • Scaphoid abdomen with respiratory distress.
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Type
Morgagni Hernia
Bochodalek Hernia
Location
Right anteromedial/Retrosternal
Most common
Left posterolateral
Defect Development
Central tendon of diaphragm

D/t enlarged Space of Larry
(Contain Superior Epigastric Artery)
(space between sternum § costal origins of diaphragm.
Pleuroperitoneal canal/membrane
Herniating Structures
Transverse colon
Stomach, spleen, transverse colon
Mnemonic
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Boche → CPM → Left
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Diagnosis:

  • Prenatal detection can be done.
    • scaphoid abdomen
  • Bowel gas shadows are present in the thorax
  • Diaphragmatic outline is not clearly visible
  • Heart shadow is not visualized due to mediastinal shift

Complications

  • 1st most common cause of death:
    • Pulmonary hypoplasia
      (due to reduced space for lung development)
      • scaphoid abdomen
      • respiratory distress and
      • features of mediastinal shift
  • 2nd most common cause of death:
    • Pulmonary hypertension (PPHN).
      • Managed with inhaled nitrates.

Management (Mx)

  • Best ventilation: IPPV (Intermittent Positive Pressure Ventilation).
  • ExUtero Intrapartum Treatment Procedure (EXIT)
    • Airway is ensured before the infant is separated from Placenta
    • Also done in Laryngeal atresia, Stenosis, Teratoma, Hygroma, Oral tumors
  • Resuscitation: 
    • with Bag and mask ventilation C/I
  • If there is severe respiratory distress
    • Intubation and bag and tube ventilation needs to be done
  • Surgical Management (Sx):
    • Circular incision around the diaphragm.
    • Bowel reduced back into abdominal cavity.
    • Mesh placed to reinforce the repair.
Congenital Pulmonary Airway Malformation → D/d for CDH
Congenital Pulmonary Airway Malformation → D/d for CDH

Eventration of diaphragm

  • Similar to CDH but not a true hernia.
  • Thinning of pleuroperitoneal membrane
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      Congenital weakness in muscles of diaphragm
      Congenital weakness in muscles of diaphragm