Diaphragmatic Hernia

An acquired diaphragmatic hernia is typically the result of progressive enlargement of normal passages through the diaphragm or, less commonly, the result of an injury or trauma, such as a fall, car accident, stab or gunshot wound.

A congenital diaphragmatic hernia (CDH) is a birth defect that results in the abnormal development of the diaphragm. CDH are rare in adults. The two most common types of CDH are Bochdalek and Morgagni.

  • Bochdalek hernia involves the side and back of the diaphragm. The stomach, liver, spleen, or intestines move into the chest cavity.
  • Morgagni hernia involves the front part of the diaphragm. The liver or intestines move up into the chest cavity.

Causes

The most common adult diaphragmatic hernia is hiatal hernia, where the stomach moves from its normal position in the abdomen into the chest, behind the heart. This occurs through the abnormally enlarged diaphragm opening (esophageal hiatus) connecting the esophagus to the stomach. The lower esophageal sphincter becomes excessively loose, allowing stomach acid and bile to flow backward into the esophagus (gastroesophageal reflux or GERD). Repeated chemical burning of the esophagus can result in scarring (stricture) and blockage.

Symptoms

  • Heartburn
  • Difficulty swallowing 
  • Food getting stuck
  • Chest pain
  • Burping

Diagnosis

  • Physical examination
  • Chest x-ray
  • Endoscopy
  • Contrast swallow
  • Esophageal manometry
  • Esophageal pH testing
  • CT scan

Treatments

Symptomatic GERD is treated with medication. Failing this, minimally invasive laparoscopic surgery is often recommended. Surgery consists of returning the stomach to its normal position within the abdomen, closing the abnormally enlarged hiatus and “wrapping” redundant stomach around the esophagus to recreate the lower esophageal sphincter pressure.  


Traumatic or congenital diaphragmatic hernias are closed surgically to repair or avoid entrapment of organs (incarceration), possibly leading to strangulation or gangrene of that organ.