What Causes Diaphragmatic Hernia?

Hiatus hernia or diaphragmatic hernia is the protrusion of an abdominal organ (or a part thereof) through the wall that normally contains it, allowing it to migrate into the chest cavity. In case of a hiatal hernia, part of the stomach protrudes upward through the opening (hiatus) at the esophagus and the diaphragm.

Diaphragmatic hernias usually result from a weakness in the muscle tissue at the esophagus opening. This weakness could be congenital or develop over time because of excessive weight gain, pregnancy, heavy lifting, constipation, or intense coughing.

Diaphragmatic paralysis could also onset suddenly due to a traumatic injury, or due to an accidental injury to Phrenic nerve (or blood-vessels thereof) during a surgical/invasive procedure.

Depending upon the underlying anatomic or neurologic etiology, the causes for diaphragmatic hernias are usually classified as follows:

• Acquired Diaphragmatic Dysfunctions because of penetrating injuries to the diaphragm, or it's rupture due to trauma.
• Anatomical defects,
• Insult to Central Nervous System (stroke),
• Congenital Diaphragmatic Defects such as: Bochdalek hernia, Diaphragmatic agenesis, and Morgagni hernia.
• Idiopathic etiologies
• Muscular disorders such as Duchenne muscular dystrophy, Metabolic myopathies, Myotonic dystrophies, and Polymyositis
• Phrenic nerve neuropathy becauses of Brachial plexus neuritis, Diabetic neuropathy, Guillain-Barré syndrome, Infections (such as diphtheria, measles, tetanus, typhoid, etc.), or Lead poisoning,
• Trauma to the phrenic nerve during a surgery,
• Spinal cord disorders (Motor neuron disease, Poliomyelitis, Syringomyelia,) and
• Traumatic injury to the cervical spinal cord.

Signs and Symptoms of Diaphragmatic Hernia / Diaphragmatic Paralysis:

Hiatal hernias are often asymptomatic. Some patients may experience severe heartburn, and have an impulse to belch frequently. In case of a strangulated hiatal hernia (part of the herniated stomach getting pinched by the diaphragm), symptoms may include severe chest pain, bloating, and difficulty in swallowing. Depending upon the underlying cause, the following symptoms may be observed:

• Congenital Diaphragmatic Hernia: Cyanosis, Respiratory distress, Bowel sounds heard in the chest,
• Traumatic Diaphragmatic Hernia: Abdominal pain, cardiac complicatioins, chest pain, dyspnea, acute respiratory distress, and orthopnea,
• Neurologic Diaphragmatic Hernia: Chest wall pain, and Exertional dyspnea.

Treatment for Diaphragmatic Hernias:

The treatment for hiatal hernias often focuses on symptomatic relief. Surgery is usually not required, except in the cases involving a strangulated hiatal hernia, or in case of a very large hiatal hernias. Phrenic nerve injury during cardiac surgery (because of cold ice chips used to slow down the heart beats, etc.) usually resolves over time.

Depending upon the underlying causes, the type of surgical intervention may include the following:

• Congenital defects: Transabdominal primary surgical repair,
• Traumatic rupture: Thoracoscopic plication of the hemidiaphragm,
• Phrenic nerve injury: Surgery attempts to repair traumatic damage to the phrenic nerve are usually not effective in restoring it's function.

Laparoscopic surgery to repair diphragmatic hernias uses a tiny surgical instrument called laparoscope, and hence the name.

Diaphragmatic Hernia Prognosis:

Prognosis for diaphragmatic hearnias due to traumatic rupture primarily depends upon the extent of injuries.

Prognosis of congenital diaphragmatic hernia patients largely depends upon the development of the lung on the herniated side. Even though congenital diaphragmatic hernia is considered to be a serious pulmonary disorder, the survival rate for infants is now better than 80%. Some infants may experience long-term respiratory complications (due to diaphragmatic paralysis) such as persistent pulmonary hypertension (PPHN).

Prognosis for the patients with hernia caused by neurologic factors depends upon the underlying causes. Prognosis for the persons with high cervical spine fractures is usually worse than the others.

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