home Adviсe Ensacculated pleurisy. Epiphrenic diverticula of the esophagus. Local relaxation of the right dome of the diaphragm. What is diaphragm relaxation

Ensacculated pleurisy. Epiphrenic diverticula of the esophagus. Local relaxation of the right dome of the diaphragm. What is diaphragm relaxation

Relaxation of the diaphragm is a pathology that is characterized by severe thinning or complete absence of the 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 means two pathologies at once, which, however, have a 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 deprived muscle fibers. It is thin, transparent, and consists mainly of layers of the pleura and peritoneum.

In the case of acquired relaxation we're talking about 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 total loss 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 injuries 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 at different speeds, that is, it can manifest itself in both 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 complaints is the displacement of the peritoneal organs into the chest. For example, part of the stomach rising, provokes a bend in the esophagus and the stomach, as a result of which the motility of the organs is disrupted, and, accordingly, pain appears. 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, gastric bleeding or 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 the powerful 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 height of the organ increases significantly, and the symptoms become more severe, surgery is recommended.

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.

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, an acquired disease occurs against the background of damage to the phrenic nerve: traumatic, surgical, inflammatory, damage due to scarring due to lymphadenitis, or 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 old age.

It is worth noting that congenital form pathology is often accompanied by other anomalies of intrauterine development, for example, cryptorchidism, heart defects, etc.

The acquired form differs from the congenital form 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 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, especially 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, since the nearby liver seems to plug the damaged area. Limited relaxation on the left may also be covered by the spleen.

With diaphragm relaxation, 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 cause of complaints is the 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.

As a rule, the 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.

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.

Surgical intervention is performed only in cases where a person has severe anatomical changes, clinical symptoms are incapacitating and cause 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.

If symptoms are mild or asymptomatic, there is no need for surgery. It is only necessary to avoid strong 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 threat to health, which cannot be said about people with traumatic and congenital hernias diaphragm. If the level of organ standing increases significantly, and the symptoms become more severe, surgery is recommended.

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.

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, an acquired disease occurs against the background of damage to the phrenic nerve: traumatic, surgical, inflammatory, damage due to scarring due to lymphadenitis, or 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 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 of intrauterine development, for example, cryptorchidism, heart defects, etc.

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 with pyloric stenosis: constant trauma from the stomach provokes degenerative changes in the muscles and their relaxation.

Symptoms

With diaphragm relaxation, 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.

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.

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.

Surgical intervention is performed only in cases where a person has pronounced anatomical changes, clinical symptoms make it incapacitating and cause severe discomfort.

The relaxation of the diaphragm was first described by Jean Petit in 1774, meaning by this concept the complete relaxation of the domes and its high standing. In clinical practice, such terms as “eventration of the diaphragm”, “primary diaphragm”, “megaphrenia” are used, and to denote limited protrusions of the dome of the diaphragm - the terms “limited relaxation of the diaphragm”, “partial eventration”, “soft” diaphragm, “ diverticulum of the diaphragm”, etc. The term relaxation of the diaphragm has received the greatest clinical recognition.

The basis of this disease is the inferiority of the muscular elements of the diaphragm. Relaxation can be congenital or acquired. Neuman (1919) considered aplasia or intrauterine injury of the phrenic nerve to be the cause of congenital underdevelopment of the diaphragm.

According to researchers, congenital relaxation is due to the constitutional inferiority of the diaphragm muscles, which subsequently leads to a secondary upward displacement. P. A. Kupriyanov (1960) considers the cause of relaxation to be a developmental defect consisting in the absence of muscle and tendon tissue in the dome of the diaphragm.

Relaxation of an acquired nature is a consequence of the inferiority of the muscle tissue of the diaphragm, which arises in connection with atrophic and dystrophic changes in the muscles, when inflammatory changes from the serous membranes transfer to it or due to independent inflammatory processes in the diaphragm, the important point is diaphragm injury. As a result of injury to the phrenic nerve, of any origin (surgery, inflammatory or tumor process), secondary neurotic muscle dystrophy develops, thinning, impaired mobility and subsequent high standing of the dome of the diaphragm.

For a long time, relaxation of the diaphragm was considered as a low-symptomatic or even asymptomatic disease, and, in contrast to diaphragmatic hernia, did not pose a threat to the patient’s life. However, along with asymptomatic, there are forms that are clinically manifested by disorders in the digestive, respiratory, cardiovascular and a number of other systems.

Symptoms of relaxation depend on the displacement of the diaphragm and adjacent organs. In each individual case, a certain group of symptoms from those organs whose function is most impaired comes to the fore. Depending on this, three groups of disorders are distinguished: respiratory, cardiovascular and gastrointestinal.

IN medical history persons suffering from this pathology note a long course of concomitant illness, an indication of past trauma to the abdomen or chest, pleurisy, tuberculosis. It should be emphasized that pleurisy can be simulated by the relaxation of the diaphragm itself.

B.V. Petrovsky and co-authors (1965) distinguish 4 forms clinical course relaxation of the diaphragm: asymptomatic, with erased clinical manifestations, with pronounced clinical symptoms and complicated (gastric volvulus, gastric ulcer, bleeding, etc.). In children they are isolated special form with severe cardiorespiratory disorders. Clinical symptoms depend on the location and degree of relaxation. It is known that left-sided relaxation is accompanied by more severe disorders.

Are common complaints are characterized by an indication of attacks of pain, weight loss, sometimes attacks of weakness, even fainting, palpitations, shortness of breath, cough. They are caused by the displacement and rotation of the heart, as well as the exclusion of half of the diaphragm from breathing.

From the gastrointestinal tract, the leading clinical symptoms are a feeling of heaviness after eating, frequent belching, hiccups, heartburn, rumbling in the abdomen, nausea, vomiting, flatulence and constipation, dysphagia and recurrent gastrointestinal bleeding. The cause of these complaints is loss of the dynamic function of the diaphragm, kinking of the abdominal esophagus, volvulus of the stomach with distension and circulatory disorders, the presence of ulcers, erosive gastritis or venous stasis and gastric bleeding. Even cases of gastric gangrene have been described.

At objective examination Hoover's symptoms are determined - a stronger deviation of the left costal arch upward and outward when inhaling. Percussion notes the increase and upward displacement of Traube's space. The lower border of the lungs in front is raised upward to the II-IV rib, the border of cardiac dullness is shifted to the right. Auscultation reveals muffled heart sounds, decreased breathing, bowel sounds and a rumbling or splashing noise over the chest.

Instrumental studies make it possible to identify disturbances in external respiration, especially vital capacity. The electrocardiogram of such patients is characterized by slowing of intraventricular conduction, impaired coronary circulation and the appearance of extrasystoles.

X-ray examination is decisive in the diagnosis of relaxation, and the following symptoms are important: 1) a persistent increase in the level of location of the corresponding dome of the diaphragm to 2-3 ribs; 2) in a horizontal position, the diaphragm and the organs adjacent to it shift upward; 3) the contours of the diaphragm represent a smooth, continuous arcuate line. Compression of the lung and displacement of the heart to the right are often detected.

A characteristic radiological sign is the Alyshevsky-Wienbeck symptom - paradoxical movements of the diaphragm, that is, rise with deep breath and lowering as you exhale. Paradoxical movements of the diaphragm are better identified when performing a functional Müller test - inhalation with the glottis closed, in contrast to the opposite direction of movement of the diaphragm on the affected side - Wellman's symptom. Holding your breath at the height of inspiration causes upward movement of the changed half of the diaphragm due to the retraction force of the lung tissue - Dillon's symptom.

With a contrast study of the stomach in the Trendelenburg position, Funstein's symptom is determined - the contrast agent spreads in the stomach, following the contours of the dome of the diaphragm. An important point is also to identify the movement of the stomach into the chest, the bend of the abdominal section, the esophagus, the displacement of the pylorus and the bend of the stomach “cascade stomach”, as well as the movement of the transverse colon, especially its splenic angle.

For differential diagnosis, pneumoperitopeum, pyelography, X-ray kymography and various functional tests are used. Pneumoperitoneum is of significant value, allowing a layer of gas to separate the dome of the diaphragm from the adjacent organs.

Local or limited relaxation of the diaphragm is observed mainly on the right. In this case, the dome of the diaphragm protrudes in an arched manner towards the lung, and the liver is deformed, repeating the shape of the relaxation area, and is wedged into the area raised upward. This circumstance often causes diagnostic errors, since the area of limited relaxation of the diaphragm is often mistaken for echinococcosis of the liver.

According to some authors, the causes of limited relaxation are the following diseases: echinococcosis of the liver and spleen, diaphragmatic-mediastinal adhesions, subdiaphragmatic abscess, supraphrenic encysted effusion, pericardial cysts, changes in the lungs, limited hypoplasia of the diaphragm and other diseases.

The more frequent localization of limited protrusions in the anteromedial part of the diaphragm on the right can be explained by the fact that in this area weak muscle bundles extend from back surface sternum. On the left, this area is covered by the parietal layer of the pericardium and the apex of the heart.

As a result of the pressure difference in abdominal cavity and the chest, a weak section of the diaphragm on the right protrudes into the chest.

The main symptom of this pathology is a partial arcuate protrusion of the anteromedial part of the diaphragm, its thinning in this area and a change in function. Accordingly, relaxation of the diaphragm marks a bulging of the liver with smooth outlines. More often, the disease is asymptomatic, but sometimes there can be various disorders, such as pain in the chest and in the heart area, cough or dyspeptic symptoms.

Treatment relaxation of the diaphragm involves surgical intervention. The indication for surgery is to establish a diagnosis of relaxation, accompanied by pain, breathing disorders, cardiovascular activity and gastrointestinal tract function. Emergency indications arise when gastric volvulus, rupture of the diaphragm, acute stomach bleeding and other serious complications.

When choosing operational access They prefer a transthoracic incision in the area of the VIII intercostal space with the intersection of the costal arch. This access is the only one possible with right-sided localization of relaxation. When relaxing the diaphragm on the left, especially in the central and anterior zones, abdominal access is used. Surgery includes plastic surgery with diaphragm tissues and autograft, as well as alloplasty.

Among the various surgical methods, the most widely used is frenopplication, the formation of a duplication after dissection or resection of a thinned area of the diaphragm. However, this operation was effective only with limited relaxations, when partially preserved diaphragm muscles were used for plastic surgery. In cases of thinning of the entire dome of the diaphragm, the risk of relapse of the disease remains.

Plastic surgery using thinned diaphragm tissue by cutting it in two mutually perpendicular directions was proposed by Lamber, West and Brosnan (1948). In this case, from the resulting four flaps, a duplication is created in the transverse, then in the longitudinal direction, forming four layers in the central part.

WITH . J. Doletsky (1959) proposed stitching the thinning zone with several rows of parallel corrugated seams. When they are tightened, the diaphragm gathers into folds and thereby ensures its strengthening and lowering of the level of location.

S. M. Lutsenko (1968) developed a method of duplication-flap tripling of the diaphragm during relaxation.

Operation technique: endotracheal anesthesia with relaxants and thoracotomy in the Vll intercostal space. First, the fusion of the diaphragm with the lung is separated. From the dome of the thinned and high-standing diaphragm present in the wound, a U-shaped flap with the base towards the spine, measuring 6-8x12-14 cm, is cut out. Then the lower surface of the diaphragm is freed from adhesions with the abdominal organs. The displaced stomach is moved to the correct position. Using two rows of U-shaped silk sutures No. 5, a duplication of the diaphragm is created by suturing the lumbocostal part of the diaphragm to its sternal part.

The resulting duplication displaces the dome of the diaphragm according to the VII-VIII rib. It is sutured to the base of the cut flap and thereby eliminates the defect. The flap is sutured with separate sutures over the duplication. In this case, the threads of a knotted two-row U-shaped seam are also used, with which both halves are hemmed s diaphragms forming duplication. This technique is positively assessed by Juvan; et al (1967), characterizing the form of sewing a pedicle flap over phrenorrhaphy as a redingote.

Thus, during the operation, a tripling of the thinned diaphragm is formed by cutting out a flap with a base at the spine, forming a duplication by suturing one part of the diaphragm over the other and then strengthening the duplication with a diaphragmatic flap.

The method of duplication-flap tripling of the diaphragm, unlike other autoplastic operations, is minimally traumatic. It makes it possible not to resort to alloplasty, which causes an exudative reaction and other complications, and also reliably eliminates relaxation of the diaphragm and eliminates associated disorders of the cardiovascular, respiratory and digestive systems.

In the complete absence of the diaphragm muscles, various plastic methods are used. Michaud et al (1955) proposed plastic surgery with a pedicled periosteal flap, and Plenk (1951) and Harti (1954) proposed a pedicled flap from the latissimus dorsi muscle, passed through an intercostal incision. There are also known attempts to use a flap from the external oblique abdominal muscle with its base at the costal arch. However, the traumatic nature of creating a muscle flap and its secondary fibrous changes do not ensure the creation of a functioning muscle barrier.

S. F. Slivnykh (1973) during relaxation used plastic surgery with preserved heterogeneous parietal peritoneum placed between the leaves of the dissected diaphragm in two cases.

Daumerie and De Backer (1949) proposed a pedicled skin flap for plastic surgery of the diaphragm. Later, this method was comprehensively studied by I. D. Korabelnikov (1951). The negative aspect of skin grafting is the danger of developing necrosis of the flap when its feeding pedicle is compressed and the inevitability of scar changes. Alloplasty of the diaphragm has been used since 1951. However, various synthetic materials (nylon, nylon) cause a pronounced exudative reaction in the pleural cavity. The original method of diaphragm alloplasty was developed by B.V. Petrovsky (1957), using a prosthesis made of polyvinyl alcohol sponge (ivalon). In this case, the ivalon plate is placed between the sheets of thinning diaphragm.

According to the authors, frenoplication provides correction of the diaphragm only with partial relaxation. With total relaxation, alloplasty is indicated according to B.V. Petrovsky using porous or mesh synthetic materials (polyvinyl alcohol, Teflon and terylene), into which connective tissue grows.

Despite the achieved results, although alloplasty creates a certain strength, it does not completely solve the problem of surgical treatment of diaphragm relaxation, since it causes an exudative reaction and requires covering the allograft with the diaphragm’s own tissues.

- this is total or limited relaxation and high standing of the dome of the thoraco-abdominal septum with prolapse of the adjacent abdominal organs into the chest. Clinically manifested by cardiovascular, respiratory, and dyspeptic disorders. The predominance of certain symptoms depends on the location and severity of the pathological process. The leading diagnostic methods are x-ray examination and CT scan organs of the chest cavity. The only treatment option is auto- or alloplasty of the diaphragmatic dome or part of it.

ICD-10

J98.6 Diaphragm diseases

General information

Relaxation of the diaphragm (diaphragm paralysis, megaphrenia, primary diaphragm) is caused by sharp dystrophic changes muscle part of the organ or a violation of its innervation. It can be congenital or acquired. Complete (total) relaxation of the thoraco-abdominal septum is more common on the left. A limited protrusion of its area (diaphragmatic diverticulum) is usually localized in the anterior medial part of the right dome. In children, relaxation of the diaphragm occurs very rarely; disturbances develop gradually as the person grows and under the influence external factors. The first symptoms appear at 25-30 years of age. Men engaged in heavy physical labor suffer more often.

Reasons for diaphragm relaxation

The high standing of the diaphragmatic dome is caused by pronounced thinning, up to complete absence, of its muscle layer. This structure of the abdominal barrier is often caused by impaired development of the organ in the prenatal period. Another common cause is paralysis of the diaphragmatic muscles. The following groups of etiological factors leading to relaxation of the diaphragm vault are distinguished:

Embryogenesis disorders. These include defects in the formation of myotomes and further differentiation of muscle elements, underdevelopment or intrauterine damage to the phrenic nerve. Congenital relaxation of the diaphragm is often combined with other developmental defects internal organs.
Damage to the diaphragmatic muscle. It can be inflammatory and traumatic. There is independent inflammation (diaphragmatitis) and secondary lesion diaphragm. The latter appears when the pathological process spreads from adjacent organs, for example, with subphrenic abscesses, pleural empyema.
Paralysis of the diaphragmatic dome. Occurs with various types of disorders of the innervation of the diaphragm. Traumatic processes lead to nerve damage, including surgical interventions. Total paralysis is caused by severe systemic neurological diseases(poliomyelitis, syringomyelia). Local lesions occur as a result of tumor invasion of the nerve trunk.

Pathogenesis

At congenital anomaly, leading to relaxation of the thoraco-abdominal septum, is detected practically complete absence muscle tissue. The thin diaphragm consists of pleural and peritoneal layers. With acquired pathology, muscle dystrophy is observed varying degrees expressiveness. Absence muscle tone leads to the loss of part of the functional abilities of the diaphragmatic vault. Due to the difference in pressure in the chest and abdominal cavities, the internal organs stretch the diaphragm, contributing to its full or partial protrusion into the area chest.

The pathological process is accompanied by compression of the lung and the development of atelectasis on the affected side, and displacement of the mediastinum in the opposite direction. Relaxation of the left dome lifts the abdominal organs upward. Volvulus of the stomach and splenic flexure of the colon occurs. There are kinks in the esophagus, blood vessels pancreas and spleen, leading to transient organ ischemia. Due to violation venous outflow The veins of the esophagus dilate and bleeding occurs. Relaxation of the right dome (usually partial) causes local deformation of the liver.

Classification

Pathological changes in internal organs and disorders of their functions depend on the causes, prevalence and localization of protrusion of the diaphragmatic septum. According to the time of occurrence and etiological factors, relaxation of the diaphragm is divided into congenital and acquired. The process can be located on the right or left, and can be total or partial. Depending on the clinical course There are 4 options for relaxing the diaphragmatic vault:

Asymptomatic. There are no manifestations of the disease. Relaxation is detected incidentally on chest x-ray.
With erased clinical symptoms. This form is characteristic of a limited, often right-sided process. The patient usually does not attach importance to unstable, weak severe symptoms diseases.
With unfolded clinical picture . It manifests itself in a variety of symptoms, depending on the degree of damage to the respiratory, digestive, and cardiovascular systems.
Complicated. Characterized by development serious complications(volvulus, stomach and intestinal ulcers, gastrointestinal bleeding and others).

Symptoms of diaphragm relaxation

Clinical manifestations of relaxation of the diaphragmatic dome are varied. Symptoms are more pronounced when congenital pathology. Limited relaxation of the diaphragm area can occur latently or with minimal complaints. In the total absence of tone of the thoraco-abdominal septum, the disease is accompanied by respiratory, cardiovascular, and dyspeptic syndromes. Most patients present general complaints of episodes of weakness and unmotivated weight loss.

Respiratory disorders are manifested by attacks of shortness of breath and dry, unproductive painful cough with little physical activity, change in body position, after eating. A clear connection between symptoms and food intake is a pathognomonic sign of diseases of the diaphragmatic dome. Cardiac activity suffers. Tachycardia, cardiac arrhythmias, and palpitations occur. Periodically, the patient is bothered by chest pain of a pressing, squeezing nature, reminiscent of cardialgia during angina pectoris.

The leading signs of diaphragm pathology are digestive disorders. Seizures acute pain in the epigastric region, right or left hypochondrium also occur after eating. Painful sensations are quite intense, last from 20-30 minutes to 2-3 hours, then stop on their own. When the esophagus is bent, swallowing is impaired. In some cases, the patient is able to swallow large pieces of solid food, but chokes on liquid (paradoxical dysphagia). Patients often complain of heartburn, hiccups, belching, nausea, and less commonly, vomiting. Patients are concerned about flatulence and periodic constipation.

Complications

Under the influence of a number of factors that increase intra-abdominal pressure, relaxation of the diaphragm, especially congenital, gradually progresses. The dome of the thoraco-abdominal obstruction can reach the level of the second rib. In this case, a pronounced displacement of internal organs occurs. The lung contracts, and areas of atelectasis form. When the stomach and intestines are pulled up, they occupy the wrong position. Because of this they develop severe complications from the digestive organs. The most common of them are volvulus of the stomach, intestines, ulcerative processes, and bleeding. Leading specialists in the field of surgery describe isolated cases of gastric gangrene.

Diagnostics

If relaxation of the diaphragmatic dome is suspected, a surgeon will conduct a diagnostic search. When interviewing the patient, he clarifies the history of injuries and operations in the chest and abdomen, inflammatory processes in the lungs, pleura, mediastinum, and upper abdominal cavity. To confirm the diagnosis, the following studies are performed:

Inspection. Sometimes it is visually possible to determine the paradoxical movement of one of the diaphragmatic domes. The diaphragm rises during inhalation and falls during exhalation. Present positive symptom Hoover - raising one of the costal arches and moving outward with a deep breath.
Percussion. The upward expansion of Traube's subphrenic space is determined. The lower border of the lung is located at the level of the II-IV rib along the anterior surface chest wall. The boundaries of absolute and relative cardiac dullness shift in the opposite direction.
Auscultation. Decreased breathing is heard in the basal parts of the lungs. Auscultation of the heart reveals muffled sounds, increased heart rate, and rhythm disturbances. In the lower part of the chest in front you can hear intestinal peristalsis and splashing sounds.
Functional studies. Spirometry makes it possible to identify restrictive disorders of external respiration function, a significant decrease in the vital capacity of the lungs. The ECG reveals slowing of intraventricular conduction, extrasystole, and signs of myocardial ischemia.
Radiation diagnostics. X-rays and CT scans of the chest are the most informative methods diaphragm studies. The radiograph visualizes the high location of one of the domes (level II–V ribs). Fluoroscopy reveals paradoxical movement of the diaphragmatic vault. The use of contrast makes it possible to identify kinks in the esophagus, stomach, and upward displacement of the digestive organs. CT most accurately determines the degree of relaxation and helps to recognize secondary pathology internal organs.

Complete relaxation of the abdominal obstruction should be differentiated from its rupture and diaphragmatic hernia. Sometimes the high standing of one of the vaults can hide a basal spontaneous pneumothorax. Partial relaxation often masks neoplastic and inflammatory processes of internal organs, pleura and peritoneum, liver and pericardial cysts.

Diaphragm relaxation treatment

The only treatment for complete or partial relaxation is surgical. Patients with a latent form of the disease and an erased clinical picture are subject to dynamic observation. They are advised to avoid excessive physical activity, eat small portions often, and avoid overeating. With the progression of the process, the presence of severe cardiovascular, respiratory or dyspeptic disorders, it is indicated surgery. Relaxation of the diaphragm, complicated by organ rupture, volvulus of the stomach, intestines, or bleeding, is subject to emergency surgical correction.

Taking into account the localization of the pathological process, laparotomy or thoracotomy is performed. A minimally invasive thoracoscopic approach has been developed. With moderate relaxation with partial preservation of muscle tone, phrenoplication is possible - excision of a thinned part of an organ with its subsequent doubling or tripling with its own diaphragmatic tissues. Complete relaxation of the right or left dome is an indication for plastic surgery with synthetic material (Teflon, polyvinyl alcohol, terylene). In pediatric surgery, the abdominal barrier is sutured with parallel rows of corrugated sutures, which are then tightened, form folds and lower the diaphragm.

Prognosis and prevention

Timely diagnosis and correct surgical tactics lead to complete recovery. The prognosis is worsened by life-threatening complications and severe concomitant pathology. Prenatal ultrasonography allows us to identify the absence of diaphragmatic muscles in the fetus. Detected relaxation must be corrected before complications develop. Injury prevention, diagnosis and adequate treatment inflammatory processes of the pulmonary parenchyma, pleura, mediastinum, drainage of subphrenic abscesses help to avoid acquired paralysis of the diaphragm.