Guidelines for the Management of Hiatal Hernia
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Congenital Diaphragmatic Hernia
orphananesthesia Anaesthesia recommendations for patients suffering from Congenital diaphragmatic hernia Disease name: Congenital Diaphragmatic Hernia (CDH) ICD 10: Q 79.0 Synonyms: CDH (congenital diaphragmatic hernia) In congenital diaphragmatic hernia (CDH) the diaphragm does not develop properly so that abdominal organs herniate into the thoracic cavity. This malformation is associated with lung hypoplasia of varying degrees and pulmonary hypertension. These are the main reasons for mortality. CDH can also be associated with other congenital anomalies (e.g. cardiac, urologic, gastrointestinal, neurologic) or with different syndromes (Trisomy 13, 18, Fryns- Syndrome, Cornelia-di-Lange-Syndrome, Wiedemann-Beckwith-syndrome and others). This malformation may be detected by prenatal ultrasound or MRI-investigation. There are several parameters which correlate prenatal findings with postnatal survival, need for ECMO-therapy, need for diaphragmatic reconstruction with a patch and the development of chronic lung disease. These findings include; observed-to-expected lung-to-head-ratio on prenatal ultrasound, relative fetal lung volume on MRI and intrathoracic position of liver and / or stomach in left-sided CDH. Depending on disease-severity, treatment can be challenging for neonatologists, paediatric surgeons and anaesthesiologists as well. Medicine in progress Perhaps new knowledge Every patient is unique Perhaps the diagnostic is wrong Find more information on the disease, its centres of reference and patient organisations on Orphanet: www.orpha.net 1 Typical surgery According to the CDH-EURO-Consortium there is a consensus on surgical repair of diaphragmatic hernia after sufficient stabilization of the neonate (delayed surgery). The definition of stability, determining readiness for surgery, depends on several parameters that have been proposed (see below). -
Morgagni Hernia Associated with Hiatus Hernia, a Rare Case Hernia De Morgagni Em Associação Com Hernia Do Hiato, Um Caso Raro
ACTA RADIOLÓGICA PORTUGUESA Janeiro-Abril 2016 nº 107 Volume XXVIII 27-29 Caso Clínico / Radiological Case Report MORGAGNI HERNIA ASSOCIATED WITH HIATUS HERNIA, A RARE CASE HERNIA DE MORGAGNI EM ASSOCIAÇÃO COM HERNIA DO HIATO, UM CASO RARO Joana Ruivo Rodrigues, Bernardete Rodrigues, Nuno Ribeiro, Carla Filipa Ribeiro, Ângela Figueiredo, Alexandre Mota, Daniel Cardoso, Pedro Azevedo, Duarte Silva Serviço de Radiologia do Centro Hospitalar Abstract Resumo Tondela-Viseu, Viseu Diretor: Dr. Duarte Silva The simultaneous occurrence of two separate A ocorrência simultânea de duas hérnias non-traumatic diaphragmatic hernias is diafragmáticas não traumáticas é extremamente extremely rare. We report a case of an old man rara. É relatado um caso de um idoso com duas Correspondência with two diaphragmatic hernias (Morgagni and hérnias diafragmáticas (hérnia de Morgagni Hiatal hernias) and we also review the clinical e do Hiato) e também revemos os aspetos Joana Ruivo Rodrigues and imagiologic features (Radiographic and clínicos e imagiológicos (Raio-X e Tomografia Rua Dr. Francisco Patrício Lote 2 Fração A Computed Tomography) of Morgagni and hiatal Computadorizada) da hérnia de Morgagni e da 6300-691 Guarda herniation. hérnia do hiato. e-mail: [email protected] Key-words Palavras-chave Recebido a 05/06/2015 Morgagni hernia; Hiatal hernia; diaphragmatic Hérnia de Morgagni; Hérnia do hiato; Hérnia Aceite a 24/11/2015 congenital hernia; chest Radiography; Computed congénita diafragmática; Radiografia torácica; Tomography. Tomografia Computorizada. Introduction intermittent, postprandial and substernal pain. The pain was not related to any type of food and was partially relieved There are only five cases of combined Morgagni and by proton pump inhibitor. -
Symptomatic Morgagni Hernia Misdiagnosed As Chilaiditi Syndrome
Case RepoRt Symptomatic Morgagni Hernia Misdiagnosed As Chilaiditi Syndrome Phyllis A. Vallee, MD Henry Ford Hospital, Department of Emergency Medicine, Detroit, MI Supervising Section Editor: Sean Henderson, MD Submission history: Submitted October 5 2010; Revision received October 21 2010; Accepted October 27 2010 Reprints available through open access at http://scholarship.org/uc/uciem_westjem Chilaiditi syndrome, symptomatic interposition of bowel beneath the right hemidiaphragm, is uncommon and usually managed without surgery. Morgagni hernia is an uncommon diaphragmatic hernia that generally requires surgery. In this case a patient with a longstanding diagnosis of bowel interposition (Chilaiditi sign) presented with presumed Chilaiditi syndrome. Abdominal computed tomography was performed and revealed no bowel interposition; instead, a Morgagni hernia was found and surgically repaired. Review of the literature did not reveal similar misdiagnosis or recommendations for advanced imaging in patients with Chilaiditi sign or syndrome to confirm the diagnosis or rule out other potential diagnoses. [West J Emerg Med. 2011;12(1):121-123.] INTRODUCTION sounds, tenderness with guarding in the epigastric and Presence of intestinal loops cephalad to the liver is an periumbilical regions and no rebound. Stool was guaiac uncommon radiographic finding. If this bowel is located above negative. the diaphragm, an intrathoracic hernia is present. If located Shortly after examination, the patient developed beneath the diaphragm, bowel interposition or Chilaiditi sign nonbilious vomiting. She received intravenous fluid, is present. When symptoms develop in these conditions, they hydromorphone for pain and ondansetron for vomiting. Initial may have similar presentations; however, management is diagnostic evaluation showed normal complete blood count, often very different. -
Massive Pneumoperitoneum Presenting As an Incidental Finding
Open Access Case Report DOI: 10.7759/cureus.2787 Massive Pneumoperitoneum Presenting as an Incidental Finding Harry Wang 1 , Vivek Batra 2 1. Internal Medicine, Thomas Jefferson University Hospitals, Philadelphia, USA 2. Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, USA Corresponding author: Harry Wang, [email protected] Abstract Pneumoperitoneum is often associated with surgical complications or intra-abdominal sepsis. While commonly deemed a surgical emergency, pneumoperitoneum in a minority of cases does not involve a viscus perforation or require urgent surgical management; these cases of “spontaneous pneumoperitoneum” can stem from a variety of etiologies. We report a case of a 72-year-old African American male with a history of metastatic pancreatic adenocarcinoma who presented with new-onset abdominal distention and an incidentally discovered massive pneumoperitoneum with no clear source of perforation on surveillance imaging. His exam was non-peritonitic, so no surgical intervention was recommended. He was treated with bowel rest, intravenous antibiotics, and hydration. He had a relatively benign clinical course with preserved gastrointestinal function and had complete resolution of his pneumoperitoneum on imaging two months after discharge. This case highlights the importance of considering non-surgical causes of pneumoperitoneum, as well as conservative management, when approaching patients with otherwise benign abdominal exams. Categories: Internal Medicine, Gastroenterology, Oncology Keywords: spontaneous pneumoperitoneum, pneumoperitoneum, pancreatic cancer, incidental finding Introduction Pneumoperitoneum is defined as the presence of free air within the peritoneal cavity. In the vast majority of cases (approximately 90%), this is a result of an intra-abdominal viscus perforation, often requiring intravenous antibiotics and acute surgical intervention [1]. -
Spontaneous Pneumoperitoneum with Duodenal
Ueda et al. Surgical Case Reports (2020) 6:3 https://doi.org/10.1186/s40792-019-0769-4 CASE REPORT Open Access Spontaneous pneumoperitoneum with duodenal diverticulosis in an elderly patient: a case report Takeshi Ueda* , Tetsuya Tanaka, Takashi Yokoyama, Tomomi Sadamitsu, Suzuka Harada and Atsushi Yoshimura Abstract Background: Pneumoperitoneum commonly occurs as a result of a viscus perforation and usually presents with peritoneal signs requiring emergent laparotomy. Spontaneous pneumoperitoneum is a rare condition characterized by intraperitoneal gas with no clear etiology. Case presentation: We herein report a case in which conservative treatment was achieved for an 83-year-old male patient with spontaneous pneumoperitoneum that probably occurred due to duodenal diverticulosis. He had stable vital signs and slight epigastric discomfort without any other signs of peritonitis. A chest radiograph and computed tomography showed that a large amount of free gas extended into the upper abdominal cavity. Esophagogastroduodenoscopy showed duodenal diverticulosis but no perforation of the upper gastrointestinal tract. He was diagnosed with spontaneous pneumoperitoneum, and conservative treatment was selected. His medical course was uneventful, and pneumoperitoneum disappeared after 6 months. Conclusion: In the management of spontaneous pneumoperitoneum, recognition of this rare condition and an accurate diagnosis based on symptoms and clinical imaging might contribute to reducing the performance of unnecessary laparotomy. However, in uncertain cases with peritoneal signs, spontaneous pneumoperitoneum is difficult to differentiate from free air resulting from gastrointestinal perforation and emergency exploratory laparotomy should be considered for these patients. Keywords: Spontaneous pneumoperitoneum, Duodenal diverticulosis, Conservative management Background therapy. We also discuss the possible etiology and clin- Pneumoperitoneum is caused by perforation of intraperito- ical issues in the management of this rare condition. -
Paraesophageal Hernia
Paraesophageal Hernia a, b Dmitry Oleynikov, MD *, Jennifer M. Jolley, MD KEYWORDS Hiatal Paraesophageal Nissen fundoplication Hernia Laparoscopic KEY POINTS A paraesophageal hernia is a common diagnosis with surgery as the mainstay of treatment. Accurate arrangement of ports for triangulation of the working space is important. The key steps in paraesophageal hernia repair are reduction of the hernia sac, complete dissection of both crura and the gastroesophageal junction, reapproximation of the hiatus, and esophageal lengthening to achieve at least 3 cm of intra-abdominal esophagus. On-lay mesh with tension-free reapproximation of the hiatus. Anti-reflux procedure is appropriate to restore lower esophageal sphincter (LES) competency. INTRODUCTION Hiatal hernias were first described by Henry Ingersoll Bowditch in Boston in 1853 and then further classified into 3 types by the Swedish radiologist, Ake Akerlund, in 1926.1,2 In general, a hiatal hernia is characterized by enlargement of the space be- tween the diaphragmatic crura, allowing the stomach and other abdominal viscera to protrude into the mediastinum. The cause of hiatal defects is related to increased intra-abdominal pressure causing a transdiaphragmatic pressure gradient between the thoracic and abdominal cavities at the gastroesophageal junction (GEJ).3 This pressure gradient results in weakening of the phrenoesophageal membrane and widening of the diaphragmatic hiatus aperture. Conditions that are associated with increased intra-abdominal pressure are those linked -
Pneumoperitoneum: an Unusual Presenting Finding of Perforated Appendicitis in Children Levent Duman
20 Case report Pneumoperitoneum: an unusual presenting finding of perforated appendicitis in children Levent Duman Pneumoperitoneum is rarely encountered as a surgical abdominal emergencies in children. However, very radiographic finding in association with perforated young children often pose a diagnostic dilemma for the appendicitis in children, and may lead to diagnostic clinician. Pneumoperitoneum is a confusing finding in errors. In this paper, we present pneumoperitoneum as perforated appendicitis, and may lead to diagnostic errors. a presenting finding of perforated appendicitis in a However, it may be considered as a favorable sign because 2-year-old boy. it will result in the patient’s immediate surgical exploration and cure. Ann Pediatr Surg 10:20–21 c 2014 Annals of The term pneumoperitoneum frequently indicates Pediatric Surgery. perforation of an intra-abdominal hollow viscus. However, it is rarely encountered as a radiographic finding in Annals of Pediatric Surgery 2014, 10:20–21 association with perforated appendicitis. The cases Keywords: appendicitis, children, pneumoperitoneum reported in the literature are mostly adult patients, but the Department of Pediatric Surgery, Su¨leyman Demirel University Medical School, relevant data in children are limited. Here, we present a Isparta, Turkey case of a 2-year-old boy with perforated appendicitis Correspondence to Levent Duman, MD, Department of Pediatric Surgery, who presented with pneumoperitoneum. The patient was Su¨leyman Demirel University Medical School, 32260 Isparta, Turkey taken into the operation theater with an initial diagnosis Tel: + 90 246 2119249; fax: + 90 246 2371758; e-mail: [email protected] of gastrointestinal perforation. Surgical exploration Received 21 July 2013 accepted 26 October 2013 indicated a perforated appendix and an appendectomy was performed. -
Congenital Diaphragmatic Hernia 1
CONGENITAL DIAPHRAGMATIC HERNIA 1 Kathy Wilson, RN BSN BA RNA CDIS 03/2019 Presentation on the Following Aspects of CDH Definition of Congenital Diaphragmatic Hernia [CDH] Clinical Presentation of CDH Surgical Repair of CDH Lifelong Sequelae of CDH CDI Considerations for CDH 2 What Is A Congenital Diaphragmatic Hernia? (CDH) A congenital diaphragmatic hernia (CDH) occurs when the diaphragm muscle — the muscle that separates the chest from the abdomen — fails to close during prenatal development, and the contents from the abdomen (stomach, intestines and/or liver) migrate into the chest through this hole. 3 KW1 KW2 4 Slide 4 KW1 This picture is from CHOP website. The actual herniated diaphragm in represented in the Left picutre. The normal diaphragm is represented on he Right. Kathy Wilson, 1/30/2019 KW2 Kathy Wilson, 1/30/2019 TYPES of CDH CDH can occur on the left side, right side or, very rarely, on both sides and vary in severity A Bochdalek hernia is a hole in the back of the diaphragm. Ninety percent of Congenital Diaphragmatic Hernias are this type A Morgagni hernia involves a hole in the front of the diaphragm Very large or incomplete diaphragmatic hernias often require ECMO immediately after delivery 5 Fetal Surgical Repair of CDH [For severe cases of CDH] Fetoscopic endoluminal tracheal occlusion (FETO) is a fetal surgery procedure that may improve outcomes in babies with the most severe cases of CDH. It is performed while infant is still in utero. 6 Postnatal Surgical Repair for Small CDH Defects An incision is made just below the baby’s rib cage, the organs in the chest are guided back down into the abdomen and the hole in the diaphragm is sewn closed. -
Chilaiditi's Sign and the Acute Abdomen
ACS Case Reviews in Surgery Vol. 3, No. 2 Chilaiditi’s Sign and the Acute Abdomen AUTHORS: CORRESPONDENCE AUTHOR: AUTHOR AFFILIATION: Devecki K; Raygor D; Awad ZT; Puri R Ruchir Puri, MD, MS, FACS University of Florida College of Medicine, University of Florida College of Medicine Department of Surgery, Department of General Surgery Jacksonville, FL 32209 653 W. 8th Street Jacksonville, FL 32209 Phone: (904) 244-5502 E-mail: [email protected] Background Chilaiditi’s sign is a rare radiologic sign where the colon or small intestine is interposed between the liver and the diaphragm. Chilaiditi’s sign can be mistaken for pneumoperitoneum and can be alarming in the setting of an acute abdomen. Summary We present two cases of Chilaiditi’s sign resulting from vastly different pathologies. The first patient was a 67-year-old male who presented with right upper quadrant pain. He was found to have Chilaiditi’s sign on the upright chest X ray. A CT scan revealed a cecal bascule interposed between the liver and diaphragm with concomitant acute appendicitis. Diagnostic laparoscopy confirmed imaging findings, and he underwent an open right hemicolectomy. The second patient was a 59-year-old female who presented with acute onset of right-sided abdominal pain. An upright chest X ray revealed air under the right hemidiaphragm, and the CT scan demonstrated a large, right-sided Morgagni-type diaphragmatic hernia. She underwent an elective laparoscopic hernia repair, which confirmed the presence of an anteromedial diaphragmatic hernia containing small bowel, colon, and omentum. Conclusion Chilaiditi’s sign can be associated with an acute abdomen. -
Herniation of the Liver: an Extremely Rare Entity Fatih Tekin, Aysenur Arslan and Fulya Gunsar
CASE REPORT Herniation of the Liver: An Extremely Rare Entity Fatih Tekin, Aysenur Arslan and Fulya Gunsar ABSTRACT We hereby present the case of a 75 years old female who was complaining of right upper quadrant abdominal pain. She had a history of cystectomy, cholecystectomy and choledochotomy operations for liver hydatid cyst 5 years ago. In addition, multiple endoscopic retrograde cholangiopancreatography sessions had been performed for recurrent biliary duct stones in the last 4 years. Radiological investigations revealed the presence of cirrhosis and the herniation of the left liver lobe through the abdominal incisional hernia defect. Secondary sclerosing cholangitis as a result of the previous operations was suggested to be the probable etiology for cirrhosis. The cirrhotic patient with an advanced age was found to be high risk for surgery. In addition, her symptoms were minimal. Thus, she was managed conservatively. Herniation of the liver is very rare. It is quite difficult to speculate any predisposing risk factors for liver herniation because of the rarity of this condition. Key Words: Herniation. Incisional hernia. Liver. INTRODUCTION Physical examination revealed minimal right upper Herniation of the liver is a rare phenomenon. Most of the quadrant tenderness on palpation and minimal case reports have been associated with congenital abdominal distension. She had an incision scar at diaphragmatic hernias or diaphragmatic hernias that epigastrium with an incisional epigastric hernia including develop after a chest trauma.1,2 There have been only a rough mass which was non-tender. Laboratory tests three previous cases where the liver has herniated revealed an alkaline phosphatase of 459 U/L (normal: through the anterior abdominal wall after an abdominal 35 - 104), gamma-glutamyl transferase of 401 U/L surgery. -
Femoral Hernia Causing Pneumoperitoneum
Postgraduate Medical Journal (1986) 62, 675-676 Postgrad Med J: first published as 10.1136/pgmj.62.729.675 on 1 July 1986. Downloaded from Femoral hernia causing pneumoperitoneum H.A. King and P.S. Boulter St Luke's Hospital, Warren Road, Guildford, Surrey GUI 3NT, UK. Summary: Richter's hernia, in which only a portion ofthe circumference ofthe intestine lies within the sac, is a common complication offemoral hernia. This case report is ofa 39 year old female who presented with apneumoperitoneum and was found at laparotomy to have a right femoral Richter's hernia containing a knuckle of perforated small bowel. This is a previously unreported presentation of femoral hernia. Introduction Richter's hernia, in which only a portion of the circumference of the intestine lies within the sac, is a common complication of femoral hernia. The bowel can strangulate and perforate but pneumoperitoneum has never been reported as a complication. Case report A 39 year old female presented with a 10-day history of copyright. generalized abdominal discomfort associated with bile stained vomiting and gross abdominal distension. Her bowels had opened daily. There was no history of previous episodes, dyspepsia or alteration in bowel habit. She had had no previous operations and was otherwise well. On examination, she was dehydrated and febrile (37.5'C), pulse rate 90/min. The abdomen was grossly http://pmj.bmj.com/ distended and tympanitic, diffusely tender but without guarding or rebound tenderness. The hernial orifices were intact. Bowel sounds were quiet and not obstruc- tive. Rectal examination demonstrated only tender- ness anteriorly. -
Giant Hiatal Hernias
PRACA CASEORYGINALNA REPORT Jan Lesinski1, Tadeusz M. Zielonka1, 2, Olga Wajtryt1, Krystyna Peplinska3, Aleksandra Kaszynska3 1Clinical Department of Internal Medicine, Czerniakowski Hospital in Warsaw, Poland 2Departement of Family Medicine, Warsaw Medical University, Warsaw, Poland 3Department of Internal Medicine and Cardiology, Solec Hospital in Warsaw, Poland Giant hiatal hernias The authors declare no financial disclosure Abstract Dyspnoea is most often caused by disorders of the respiratory and/or cardiovascular systems. Much less often it is brought about by the displacement of abdominal organs into the thoracic cage. Hiatal hernias may give rise to diagnostic difficulties, as both clinical and radiological symptoms suggest different disorders. Computed tomography is the method of choice when making a diagnosis. We have presented a series of 7 cases of giant hiatal hernias, each with a varying course of the disease, clinical symptoms, radiological features and prognoses. In two of the cases, the hernias were of a post-traumatic nature. Four cases of large diaphragmatic hernias were found in elderly patients (over 90 years old). An advanced age and numerous coexisting chronic diseases disqualified most of the patients from surgical treatment despite the hernias’ large sizes. In only one case was fundoplication performed with a good end result. Two patients died, and an extensive hernia was the cause of one of the deaths. Upper gastrointestinal symptoms were present only in a few of the patients. An early diagnosis of giant hiatal hernia is crucial for the patients to undergo prompt corrective surgeries. Key words: acquired diaphragmatic hernia, dyspnoea, elderly patients, gastroesophageal reflux disease, kyphoscoliosis, hiatal hernia Adv Respir Med.