PICTORIAL ESSAY OF DIAPHRAGMATIC HERNIA Abstract no:1015

.Congenital -Bochdalek . Diaphragmatic hernia is defined as congenital or acquired defect in the diaphragm. Depending on the location and size of defect , retroperitoneal and intra abdominal organs can prolapse into the thoracic cavity due to negative intra thoracic pressure. .Congenital -Bochdalek . -Morgagni . .Acquired - Traumatic - Hiatal - Iatrogenic.

CONGENITAL DIAPHRAGMATIC HERNIA Bochdalek hernia is a form of congenital diaphragmatic hernia with an estimated frequency of 1 per 2,000 to 5,000 live births [1] Occur posteriorolaterally and are due to a defect in the posterior attachment of the diaphram when there is a failure of pleuroperitoneal membrane closure in utero.  Retro peritoneal or intra abdominal structures may prolapse through the defect. Complications are usually due to pulmonary hypoplasia[2,3]. In adults, incidentally-discovered posterior diaphragmatic hernias are rare (0.17% of patients having an abdominal CT).

Chest Xray PA view: Elevated left hemidiaphragm with bowel loops seen herniated to thoracic cavity. CT Thorax: Defect in the left hemidiaphragm through which bowel loops seen herniating into thoracic cavity. Chest Xray AP view: Large left Bochdalek hernia and right sided tension pneumothorax. Minimal mediastinal displacement by herniated bowel in Left chest.

CONGENITAL DIAPHRAGMATIC HERNIA  Morgagni hernia is a form of retro sternal hernia and accounts for approximately 2% of all congenital diaphragmatic hernias.  It is characterized by herniation through the foramen of morgagni . In asymptomatic individuals, surgical repair is still recommended because theres risk of bowel prolapse and subsequent strangulation. As compared to the Bochdalek hernia, the Morgagni hernia is: rare small anterior at low risk of prolapse

Chest Xray AP (A) and Lateral(B): Showing intra thoracic bowel herniating through anterior foramen of Morgagni defect.

The second form of retrosternal hernia happens as a component of the Pentalogy of Cantrell. Includes a number of congenital defects including omphalocele, inferior sternal cleft, complex cardiac defects, ectopia cordis, diaphragmatic hernia, and pericardial defects The deformity results from a failure of development of the septum transversum .

HIATUS HERNIA Herniation of abdominal contents through oesophageal hiatus into thoracic cavity[3]. Most patients are asymptomatic and it is an incidental finding. However, symptoms may include epigastric/chest pain, post prandial fullness, nausea and vomiting . Common herniated content is stomach. Sub types – Sliding - Rolling(Para oesophageal) - Mixed type.

Sliding hiatus hernia The most common type of hiatus hernia (95%). The gastro oesophageal junction is usually displaced by more than 2 cm above the hiatus. The oesophageal hiatus is often abnormally widened to 3-4 cm (the upper limit of normal is 15 mm). The gastric fundus may also be displaced above the diaphragm and present as a retro cardiac on a chest radiograph. The presence of an air-fluid level in the mass suggests the diagnosis. Small, sliding hiatus hernias commonly reduce in the upright position.

Rolling (para-oesophageal) hiatus hernia Less common than the sliding type. The gastro esophageal junction remains in its normal location while a portion of the stomach herniates above the diaphragm. Includes a peritoneal layer that forms a true hernia sac, distinguishing it from the more common sliding hiatal hernia. A sliding hernia does not have a hernia sac and slides into the chest since the gastroesophageal junction is not fixed inside the abdomen.

MIXED OR COMPOUND The mixed or compound hiatal hernia is the most commonest type of para-oesophageal hernia. The gastro oesophageal junction is displaced into the thorax with a large portion of the stomach, which is usually abnormally rotated.

Mixed hiatal hernia: CT Thorax showing herniation of abdominal contents along with Gastro oesophageal junction through the hiatus into thoracic cavity.

ACQUIRED DIPAHRAMATIC HERNIA Traumatic: Blunt abdominal trauma can also result in traumatic diaphragmatic hernia in older children. The diagnosis is missed on initial chest radiographs in up to 47% of patients. CT or MRI is often necessary to make a definitive diagnosis[4,5]

A B C Scanogram (A)showing multiple bowel loops in thoracic cavity. Pre contrast (B) post contrast(C) defect noted at the convexity of the left hemi diaphragm with herniation of the splenic flexure and its attached mesentery.

Refernces: 1.Stege G, Fenton A, Jaffray B (2003) Nihilism in the 1990s: the true mortality of congenital diaphragmatic hernia. Pediatrics 112:532–535 2.Skandalakis JE, Gray SW, Ricketts RR (1994) The diaphragm. In: Skandalakis JE, Gray SW (eds) Embryology for surgeons, 2nd edn. Williams & Wilkins, Baltimore, pp 491–539 3. Stolar CJH (1997) Congenital diaphragmatic hernia. In: Oldham KT, Colombani PM, Foglia RP (eds) Surgery of infants and children: scientific principles and practice. Lippincott-Raven, 4. Ramos CT, Koplewits BZ, Babyn PS et al (2000) What have we learned about traumatic diaphragmatic hernias in children? J Pediatr Surg 35:601–604 5. Cigdem MK, Onen A, Otcu S et al (2007) Late presentation of Bochdalek-type congenital diaphragmatic hernia in children: a 23- year experience at a single center. Surg Today 37:642–645iladelphia, pp 883–895