Relaxation of the diaphragm is a pathology that is characterized by a sharp thinning or complete absence muscle layer of the organ. This appears due to abnormal development of the fetus or as a result pathological process, the one that led to the protrusion of the organ into the chest cavity.
In fact, this term in medicine refers to two pathologies at once, which, however, have similar clinical symptoms and both are caused by the developing protrusion of one of the domes of the organ.
A congenital anomaly of formation is characterized by the fact that one of the domes is devoid of muscle fibers. It is thin, transparent, and consists mainly of layers of the pleura and peritoneum.
In the case of acquired relaxation, we are talking about muscle paralysis and their further atrophy. In this case, two options for the development of the disease are possible: the first is a lesion with a complete loss of tone, when the diaphragm is similar to a tendon sac, and muscle atrophy is quite pronounced; the second is impaired motor function while maintaining tone. The origin of the acquired form is facilitated by damage to the nerves of the right or left dome.
Causes of pathology
The congenital form of relaxation can be provoked by abnormal formation of diaphragm myotomes, as well as impaired muscle differentiation, and intrauterine trauma/aplasia of the phrenic nerve.
The acquired form (secondary muscle atrophy) can be caused by inflammatory and traumatic damage to the organ.
Also, the acquired disease appears against the background of damage to the phrenic nerve: traumatic, surgical, inflammatory, damage by scars due to lymphadenitis, tumor.
The congenital form leads to the fact that after the birth of the child, the organ cannot bear the load placed on it. It gradually stretches, which leads to relaxation. Stretching can occur with at different speeds, that is, it can manifest itself both in early childhood, and in the elderly.
It is worth noting that the congenital form of pathology is often accompanied by other anomalies of intrauterine development, say, cryptorchidism, heart defects, etc.
The acquired form differs from the congenital form not by absence, but by paresis/paralysis of muscles and their further atrophy. In this case, complete paralysis does not occur, and therefore the symptoms are less pronounced than in the congenital form.
Acquired relaxation of the diaphragm may appear later than secondary diaphragmitis, say, with pleurisy or subphrenic abscess, as well as after organ injury.
The disease can be provoked by stretching of the stomach due to pyloric stenosis: continuous trauma from the stomach provokes degenerative metamorphosis of the muscles and their relaxation.
Symptoms
Manifestations of the disease may vary from case to case. For example, they are very pronounced in congenital pathology, but in acquired, exclusively partial, segmental pathology, they may be completely absent. This is due to the fact that the acquired one is characterized by a lower degree of tissue stretching and a lower position of the organ.
In addition, the segmental localization of pathology on the right is more favorable, because the nearby liver, as it were, plugs the damaged area. Limited relaxation on the left may also be covered by the spleen.
When the diaphragm relaxes, signs rarely appear in childhood. The disease most often manifests itself in people 25-30 years old, exclusively in those who engage in heavy physical labor.
The main reason for the claims is the displacement of the peritoneal organs in chest. For example, part of the stomach rising, provokes a bend in the esophagus and personal, as a result of which the motility of the organs is disrupted, and accordingly, the appearance of painful sensations. Kinking of the veins can lead to internal bleeding. These signs of the disease intensify after meals and physical activity. In this environment pain syndrome provokes bending of the vessels feeding the spleen, kidney and pancreas. Attacks of pain can reach high intensity.
As a rule, the pain syndrome manifests itself acutely. Its duration varies from several minutes to several hours. At the same time, it ends as quickly as it begins. Often the attack is preceded by nausea. It is noted that the pathology may be accompanied by difficulty passing food through the esophagus, as well as bloating. These two phenomena quite often occupy a leading place in hospital pathology.
Most patients complain of attacks of pain in the heart area. These can be caused by both vagal reflux and direct pressure on the organ exerted by the stomach.
Diagnostic methods
The main way to detect relaxation is x-ray examination. Occasionally, during relaxation, doubt arises about the presence of a hernia, but check differential diagnosis Without an x-ray examination it is virtually unthinkable. Only rarely do the peculiarities of the course of the disease and the nature of its development make it possible to correctly determine the pathology.
The doctor, conducting a physical examination, discovers the following phenomena: the lower border of the left lung shifts upward; the zone of subphrenic tympanitis spreads upward; Intestinal peristalsis can be heard in the pathology zone.
treatment
In this situation, there is only one way to eliminate the disease - surgery.
However, operations are not performed far away for every patient. Testimony is required to do this.
Surgical intervention is performed only in cases where a person has pronounced anatomical metamorphoses, Clinical signs disables work and causes severe discomfort.
Also, indications for surgery are complications that pose a threat to life, for example, rupture of the diaphragm, stomach bleeding or its acute volvulus.
Deciding on Relaxation Therapy surgically, doctors also consider the presence of contraindications to this, as well as all general state patient.
If symptoms are mild or asymptomatic, there is no need for surgery. You just need to avoid intense physical activity, stress, overeating, and also monitor the regularity of bowel movements. In this case, the patient can remain under the supervision of doctors for years without any danger to health, which cannot be said about people with traumatic and congenital hernias of the diaphragm. If the stage of the organ increases significantly and the symptoms become more severe, surgery is recommended.
The human diaphragm is the most important respiratory muscle. It is absolutely unique in its structure.
The human diaphragm is made in the form of a flat membrane stretched horizontally inside the body. It is the boundary between the abdominal and thoracic cavities. The diaphragm consists of muscle and tendon parts, the right and left dome. In addition, it contains openings for the esophagus and aorta.
The structure of the diaphragm contains a large number of muscle fibers. They start from the chest walls and converge, connected by tendons, in the center. According to the areas of fiber attachment, the diaphragm is divided into costal, sternal and lumbar parts.
When contracting and relaxing, the respiratory membrane regulates the volume of the chest cavity. The human diaphragm also facilitates the flow of venous blood to the heart by increasing suction pressure as the chest cavity expands. In addition, the respiratory membrane is involved in maintaining normal constant pressure in the abdominal region and stable anatomical interaction of organs.
With traumatic or inflammatory damage to the phrenic nerves, acquired relaxation of the diaphragm occurs. It is manifested by a one-sided persistent high standing of a thinned but not losing continuity of the membrane, provided that it is attached to a normal area. Relaxation can also be innate.
A distinction is also made between complete and partial relaxation of the membrane. With complete relaxation, the entire dome relaxes, and with partial relaxation, only a part rises up.
There are cases of special surgical damage to the phrenic nerves. This may be due to the resulting “free” pleural cavity, for example, when a lung is removed. Damage to the phrenic nerve leads to relaxation of the membrane, it rises, thus reducing the “empty” pleural cavity.
Complete or partial relaxation of the diaphragm may be accompanied by breathing or disturbance. An accurate diagnosis of the disorder is established when x-ray examination.
During relaxation, the human diaphragm has a regular, continuous, arched contour. All organs are located under the membrane; there are no retractions on the walls of the intestine and stomach. During relaxation, the x-ray picture is characterized by constancy.
Complete or limited relaxation of the membrane manifests itself mainly with right side. This may be due to the presence of weak muscle bundles extending from this side of the posterior surface of the sternum. Relaxation of the right dome of the diaphragm is accompanied by its arched protrusion towards the lung and deformation of the liver. In this case, the liver repeats the area of relaxation, wedging into it. This circumstance is often the reason diagnostic errors, since the area of relaxation is taken as although, according to a number of experts, the latter can cause relaxation of the diaphragm.
In many cases, such right-sided relaxation occurs without symptoms. However, sometimes it is accompanied by various disorders (chest and heart pain, cough or (digestive upset)).
Prescribed as treatment surgery. One of the surgical options is the creation of a diaphragm duplication by thoracoscopic plastic surgery using allografts. This technique allows for intervention at the initial stages of development of the disorder. At the same time, the risk of injury during surgery is significantly reduced.
Relaxation of the diaphragm is understood as a one-sided high standing of the dome of the diaphragm, extremely thinned, but maintaining continuity.
The term "relaxation" is now accepted by the majority to denote this suffering. However, in the literature there are also other names such as: eventration of the diaphragm (the name is unfortunate, it gives reason to imply a hernia), insufficiency of the diaphragm, idiopathic high standing, unilateral persistent increase in the diaphragm, megadiaphragm (which is incorrect).
The study shows the absence of muscle elements; between the serous layers there is only fibrous tissue.
From organs abdominal cavity the stomach and large intestine protrude high up, then, less often small intestine. The stomach displaced upward undergoes the same changes in position as with a diaphragmatic hernia: the greater curvature faces upward, adjacent to the diaphragm. The lung is compressed according to the height of the rise of the diaphragmatic septum, the heart is shifted to the right during left-sided relaxation.
There is every reason to consider the relaxation of the diaphragm congenital anomaly, a consequence of insufficient muscle formation, which normally grows into poorly differentiated mesenchymal tissue separating the body cavities. Relaxation of the diaphragm can be combined with other defects. Sometimes it is discovered in childhood. The fact that the disease is most often diagnosed at the age of 30-40 years is explained by the gradual stretching and increase in the level of the diaphragmatic septum as a result of pressure from the abdominal organs due to tension in the abdominal muscles.
Some assume not only a congenital, but also an acquired origin of relaxation of the diaphragm, not only agenesis, but also atrophy of muscle elements. Trauma very rarely precedes relaxation of the diaphragm, and if such a temporal relationship appears to exist, there is no evidence of the absence of relaxation before injury. Vast experience suggests that transection of the phrenic nerve leads to relaxation of the diaphragmatic septum, but not to its total degeneration. At the same time, one must take into account Kigyo's studies on monkeys, which showed that the combination of transection of the phrenic nerve with transection sympathetic innervation gives an identical disease.
Symptoms of diaphragm relaxation
The severity of clinical manifestations of diaphragm relaxation varies - from the complete absence of symptoms to significant disorders. There are changes in the position of the abdominal organs, especially the stomach, colon, as well as compression of the lung, displacement of the heart, very similar to what is observed with a diaphragmatic hernia. This explains why the clinical symptomatology of both diseases largely coincides. The most significant difference is that during relaxation there is no pinching.
Manifestations of the disease are combined into the following clinical syndromes:
- digestive, in the form of dysphagia, including paradoxical, vomiting, pain in the pit of the stomach, feeling of heaviness, constipation;
- respiratory, manifested by shortness of breath after physical exertion, after eating;
- cardiac - in the form of palpitation of the heart, tachycardia, anginal phenomena.
Objective examination by conventional clinical methods can detect the same changes as those found in diaphragmatic hernia, and the same variability in the results of the study due to different position body or the degree of filling of the stomach.
The only method to distinguish relaxation of the diaphragm from a hernia is an x-ray examination. It makes it possible to determine whether the displaced organs are located under or above the diaphragmatic septum. The borderline thoraco-abdominal line can be formed by both the diaphragmatic septum and the greater curvature of the stomach, facing cranially. The diagnosis of diaphragm relaxation is undoubted if the contours of the diaphragmatic septum and the contours of the stomach are clearly separable. If the upper contours of the stomach and colon are located on different levels and the diaphragm strip is not visible between them, the diagnosis of a hernia is more likely, especially when the height of the organs changes differently when the body is positioned head down. With relaxation, the relationship is more permanent. If one contour is visible, then by reducing the amount of air in the stomach, you can either separate its wall from the diaphragm, or establish that the broken boundary line is formed by the stomach. Repeated x-ray studies show a relative constancy of the picture during relaxation and greater variability during hernia.
For the purpose of differential diagnosis, it is recommended to use gaeumoperitoneum. Air introduced into the abdominal cavity, while the diaphragm is intact, will separate it from the shadow of the stomach and intestines. When there is a hole in the diaphragm, air enters the pleural cavity. However, with adhesions in the hernial orifice, air will remain in the abdominal cavity.
Diaphragm relaxation treatment
Relaxation of the diaphragm can only be eliminated surgically. Indications for diaphragm relaxation are decided individually, taking into account the magnitude of the elevation of the abdominal organs and the severity of clinical symptoms. The objective of the operation is to reconstruct the diaphragm, resulting in abdominal and thoracic organs should take a normal position.
You can excise a section of the diaphragm and sew the edges of the cut with a frock stitch. If the reduction of the diaphragm is insufficient, it is recommended to apply a second and third row of sutures. To strengthen the very thin diaphragmatic septum, after excision of part of it, the psoas muscle, intercostal muscles, skin, and fascia lata of the thigh were used. The aperture doubling method is close to the indicated one. These operations are best performed using a thoracic approach.
The diaphragmatic septum can be reduced by forming a fold. The diaphragm duplication flap is fixed with sutures or back wall chest and abdomen, or to the anterior abdominal wall.
To flatten the diaphragm, it is also proposed to apply corrugated sutures (back to front or front to back) using both thoracic and abdominal approaches.
The above surgical methods are used less and less, and the use of alloplastic materials to strengthen the diaphragm is coming to the fore. Nylon, nylon, and polyvinyl alcohol were used. It is recommended to place alloplastic material between the leaves of the dissected diaphragmatic septum. For these operations, thoracic access is appropriate. The method, developed in detail by Petrovsky, consists of the following: after dissecting the diaphragm, a polyvinyl alcohol plate measuring 30 X 25 X 0.7 cm is placed on the outer half of the diaphragm and sutured with silk to the prevertebral fascia and muscles chest wall, then to the remnants of the diaphragm at the pericardium and to the anterior wall of the chest along the projection of the medial borders of the left dome of the diaphragm. The medial leaf of the diaphragm is placed on the graft.
The article was prepared and edited by: surgeonRelaxation of the diaphragm is a persistent one-sided high position of the diaphragm with its normal attachment to the lower aperture of the chest, accompanied by movement of the abdominal organs.
Etiology
The cause of this disease is the inferiority of the muscular elements of the diaphragm. Inferiority can be like congenital(organ aplasia, intrauterine injury to the phrenic nerve, malformation - absence of muscle and tendon tissue in the dome of the diaphragm), and acquired(atrophic and dystrophic changes in muscles, transition inflammatory phenomena from the serous covers of the abdominal organs, inflammation, trauma or neoplasm of the diaphragm). The reasons for limited relaxation of areas of the dome of the diaphragm are echinococcosis of the liver and spleen, subphrenic abscess, supradiaphragmatic encysted pleurisy, pericardial cysts, diaphragmatic-mediastinal adhesions.
Classification:
· full;
· partial.
By clinical course :
· asymptomatic;
· with erased clinical manifestations;
· with pronounced clinical manifestations;
· complicated (gastric volvulus, gastric ulcer, bleeding, etc.).
Clinic
Clinical manifestations depend on the location and severity of relaxation. Left-sided relaxation occurs with more pronounced disturbances due to cardiorespiratory syndrome. IN clinical picture Pathological symptoms can be identified from the digestive, respiratory, of cardio-vascular system, general symptoms. Complaints are caused by displacement and rotation of the mediastinum, as well as dysfunction of the diaphragm.
Patients complain of a feeling of heaviness after eating, frequent belching, hiccups, heartburn, rumbling in the abdomen, nausea, vomiting, flatulence and constipation, dysphagia, recurrent gastrointestinal bleeding. The causes of these complaints are a violation of the static (supporting) function of the diaphragm, kinking of the abdominal esophagus, volvulus of the stomach with subsequent distension and disruption of blood supply up to its gangrene, the presence of ulcers and erosions.
In patients with diaphragm relaxation, shortness of breath, tachypnea, and cough are noted. Tachycardia, rhythm disturbances, and pain in the heart area occur. This symptomatology is associated with displacement and rotation of the mediastinum, excluding part of the diaphragm from breathing. In addition, patients note weight loss and weakness.
Diagnostics
Syndromes and symptoms of diaphragm relaxation:
1. Hoover's symptom - a stronger deviation of the left costal arch upward and outward when inhaling.
2. Alshevsky-Winbeck symptom - paradoxical movement of the diaphragm (rising during deep inspiration and lowering during exhalation).
3. Funstein's sign - the contrast agent spreads in the stomach, following the contours of the dome of the diaphragm.
4. Dillon's phenomenon - radiographs reveal an accelerated upward displacement of the relaxed dome of the diaphragm in the phase of maximum exhalation.
5. Cofferat syndrome is a congenital or traumatic (birth) unilateral paralysis of the diaphragm, which is often accompanied by symptoms of loss of cervical plexus function (shortness of breath, chest rapid breathing, cyanosis, sunken abdomen, intestinal dysfunction).
6. Grzan syndrome - unilateral paresis or paralysis of the diaphragm caused by cervical osteochondrosis and manifested by relaxation of the diaphragm.
7. Phrenic nerve syndrome - paresis or paralysis of the diaphragm, manifested by weakening of the cough impulse and high standing, as well as immobility of the dome of the diaphragm.
Relaxation of the diaphragm is a pathology that is characterized by a sharp thinning or complete absence of the muscle layer of the organ. This occurs due to abnormal development of the fetus or as a result of a pathological process that led to protrusion of the organ into the chest cavity.
In fact, this term in medicine refers to two pathologies at once, which, however, have similar clinical symptoms and both are caused by a progressive protrusion of one of the domes of the organ.
A congenital malformation is characterized by the fact that one of the domes is devoid of muscle fibers. It is thin, transparent, and consists mainly of layers of the pleura and peritoneum.
In the case of acquired relaxation, we are talking about muscle paralysis and subsequent atrophy. In this case, two options for the development of the disease are possible: the first is a lesion with a complete loss of tone, when the diaphragm is similar to a tendon sac, and muscle atrophy is quite pronounced; the second is impaired motor function while maintaining tone. The appearance of the acquired form is facilitated by damage to the nerves of the right or left dome.
Causes of pathology
- An innate form of relaxation can provoke abnormal formation of diaphragm myotomes, as well as impaired muscle differentiation, and intrauterine trauma/aplasia of the phrenic nerve.
- Acquired form(secondary muscle atrophy) can be caused by inflammatory and traumatic damage to the organ.
Also acquired disease occurs against the background of damage to the phrenic nerve:
- traumatic;
- operating rooms;
- inflammatory;
- damage due to scarring due to lymphadenitis;
- tumor.
Congenital form leads to the fact that after the birth of a child the organ cannot bear the load placed on it. It gradually stretches, which leads to relaxation. Stretching can occur at different rates, that is, it can appear both in early childhood and in old age.
It is worth noting that the congenital form of the pathology is often accompanied by other anomalies intrauterine development, for example, cryptorchidism, heart defects, etc.
Acquired form differs from congenital not by absence, but by paresis/paralysis of muscles and their subsequent atrophy. In this case, complete paralysis does not occur, so the symptoms are less pronounced than with the congenital form.
Acquired relaxation of the diaphragm can occur after secondary diaphragmitis, for example, with pleurisy or subdiaphragmatic abscess, as well as after organ trauma.
The disease can be provoked by stretching of the stomach due to pyloric stenosis:
Constant trauma from the stomach provokes degenerative changes in the muscles and their relaxation.
Symptoms
- Manifestations of the disease may vary from case to case. For example, they very pronounced when congenital pathology , and with acquired, especially partial, segmental, they may be completely absent. This is due to the fact that the acquired one is characterized by a lower degree of tissue stretching and a lower position of the organ.
- Besides, segmental localization of pathology on the right is more favorable, since the nearby liver, as it were, plugs the damaged area. Limited relaxation on the left may also be covered by the spleen.
- When relaxing the diaphragm, symptoms rarely occur in childhood. The disease most often manifests itself in people 25-30 years old, especially in those who engage in heavy physical labor.
- The main reason for complaints is displacement of the peritoneal organs into the chest. For example, part of the stomach rising, provokes a bend in the esophagus and its own, as a result of which the motility of the organs is disrupted, and, accordingly, pain occurs. Kinking of the veins can lead to internal bleeding. These signs of the disease intensify after meals and physical activity. In this situation, the pain syndrome provokes kinking of the vessels feeding the spleen, kidney and pancreas. Attacks of pain can reach high intensity.
- Usually, pain syndrome manifests itself acutely. Its duration varies from several minutes to several hours. Moreover, it ends as quickly as it begins. The attack is often preceded by nausea. It is noted that the pathology may be accompanied by difficulty passing food through the esophagus, as well as bloating. These two phenomena quite often occupy a leading place in the pathology clinic.
- Most patients complain of attacks of pain in the heart area. These can be caused by both vagal reflux and direct pressure on the organ exerted by the stomach.
Diagnostic methods
The main method for detecting relaxation is X-ray examination. Sometimes, during relaxation, a suspicion of the presence of a hernia arises, but it is almost impossible to carry out a differential diagnosis without an x-ray examination. Only sometimes the features of the course of the disease and the nature of its development make it possible to accurately determine the pathology.
Doctor conducting physical examination, detects the following phenomena:
- the lower border of the left lung shifts upward;
- the zone of subphrenic tympanitis spreads upward;
- Intestinal peristalsis can be heard in the pathology zone.
Treatment
In this situation, there is only one way to eliminate the disease - surgery.
However, not all patients undergo surgery. To do this, testimony is needed.
- Surgery is performed only in cases where a person has pronounced anatomical changes, clinical symptoms disables work and causes severe discomfort.
- Also, indications for surgery are complications that pose a threat to life, for example, rupture of the diaphragm, gastric bleeding or acute volvulus.
When deciding whether to treat relaxation surgically, doctors also take into account the presence of contraindications to it, as well as the general condition of the patient.
