Diaphragm paralysis symptoms. What is diaphragm dome relaxation and what are its consequences? I

Paralysis and paresis of the diaphragm

Paralysis of the diaphragm is characterized by its high standing and lack of respiratory movements. Unlike a hernia, there is no hernial orifice or sac. The muscular-ligamentous component is preserved throughout (especially in the early stages of the disease), when its atrophy has not yet set in.

Diaphragmatic paralysis in newborns usually occurs due to birth trauma as a result of damage to the cervical spinal roots related to the phrenic nerve. Similar isolated birth injury This happens rarely; more often all roots are damaged brachial plexus with the development of paralysis of the upper limb, and the phrenic nerve is sometimes involved in the process.

Approximately 5% of newborns who have suffered neonatal trauma exhibit varying degrees of diaphragmatic paresis, which in most cases is combined with Erb's palsy. In infants and older children, paresis of the diaphragm occurs as a result of damage to the phrenic nerve during surgery, during puncture of the subclavian veins, or due to involvement of the nerve in the inflammatory process during empyema of various origins, tumor lesions.

Clinic and diagnostics

The most severe clinical picture is observed with diaphragm paralysis in newborns: respiratory failure with shortness of breath and cyanosis is pronounced, breathing is often arrhythmic with retraction yielding places chest, the borders of the heart are shifted to the healthy side, breathing is heard worse on the affected side. Most children show symptoms of cardiovascular disorders.

The diagnosis can only be made by x-ray examination. The characteristic feature is the high position of the dome of the diaphragm, its contour has a clear hemispherical shape, the mediastinal organs are shifted to the healthy side. Synchronous breathing movements There is no diaphragm; more often it is motionless, but paradoxical movements are also possible.

Treatment

Treatment depends on the severity of the condition, the severity of hypoxia and respiratory disorders. Usually start with conservative therapy, aimed at maintaining cardiac activity and adequate pulmonary ventilation. In addition to constant oxygenation, breathing is periodically carried out with increased resistance during exhalation.

If there is no effect, connect an auxiliary or artificial respiration. Provide stimulation to improve recovery processes, muscle trophism and conductivity nerve impulses. It is imperative to use cervical electrophoresis with proserin, aloe, lidase, and prescribe vitamins and anticholinesterase drugs (proserin).

If there is no effect, use after 2-3 weeks surgery, which consists in performing a thoracotomy and applying mattress collecting sutures in such a way that the dome of the diaphragm is flattened. It must be remembered that the phrenic nerve and its main branches should not get into the sutures, since in the long term it is possible to restore the function of the diaphragm. The results are largely determined by the degree of damage to the central nervous system and the severity of associated inflammatory changes in the lungs. Usually, after surgery, children's condition begins to improve quickly.

Foreign bodies of the trachea and bronchi

Foreign body aspiration (FB) is quite common in children. All researchers note that this type pathology is typical for childhood (more than 90% of cases); while most often this pathology occurs in children aged 1 to 3 years. According to the results of review statistics, the frequency of foreign body aspiration is 3.7 per 1000 children. It should be noted that throughout the world, otolaryngologists primarily deal with this pathology in children and, as a rule, only in acute period(within 24 hours) after aspiration of FB. This circumstance explains the significant frequency of undetected aspirations, especially in young children.

Marked various options mechanical obstruction (according to G.I. Lukomsky):

end-to-end or partial;
valve;
full

All children with late diagnosing IT of the tracheobronchial tree, partial obstruction is noted, which determines the possibility of long-term carriage of IT. Most ITs (mostly of organic origin) are eliminated due to cough impulses or the action of mucociliary transport, but some are retained in respiratory tract and can cause chronic inflammation in the lungs.

Clinic

The clinic depends on the size of the IT, its location and origin (organic or inorganic). Aspiration of several foreign bodies at once, aspiration of liquid or food may also be observed, which also affects clinical symptoms. Complete blockage of a bronchus can lead to atelectasis of the segment or lobe ventilated by this bronchus. Obstruction of the trachea causes an acute attack of suffocation, which, if not treated timely assistance, can lead to serious complications, including death.

However, IT may not completely obstruct the airways, leading to partial disruption of ventilation in this area, or creating a valve mechanism with the subsequent development of emphysema, involving various volumes of the affected lung. Clinical and radiological the characteristic, of course, depends on the period that has passed since the aspiration of IT. Auscultation There is a weakening of breathing, wheezing of various types, as well as uncharacteristic breathing noises. In children with early dates from the moment of aspiration to radiographs were identified:

emphysema of a segment or lobe,
decreased pneumatization of the lung area,
atelectasis of a segment or lobe.

Very effective method investigation for suspected FB aspiration is chest fluoroscopy with the identification of pathological mobility of the median shadow (positive Holtznecht-Jacobson sign).

Treatment

The main method of treatment is endoscopic extraction foreign body using a rigid respiratory bronchoscope with optical forceps with different shapes of working parts. Only in in rare cases if bronchological removal of a foreign body fails due to the nature of the FB or the development of suppuration, it is necessary to resort to thoracotomy with bronchotomy or resection of the affected area of the lung.

Bychkov V.A., Manzhos P.I., Bachu M. Rafik H., Gorodova A.V.

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 due to pathological process, which led to 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 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're talking about about muscle paralysis and their 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

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.

Acquired form ( secondary atrophy muscles) 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 speeds, that is, it can appear both in early childhood, and in the elderly.

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 with 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 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 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. 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.

The doctor performing 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, 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.

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Worst Best

The diaphragm is the main muscle providing pulmonary ventilation, and its value can be compared to a certain extent with the value of the heart muscle, which carries out blood circulation. Decompensation of the function of the diaphragm is the most important mechanism thanatogenesis in patients dying from respiratory failure for acute or chronic pathology lungs. However, this chapter will consider only those ventilation disorders that arise as a result of pathology of the diaphragm itself. This pathology includes diaphragm paralysis, diaphragm relaxation, diaphragmatic hernia of various origins and some other conditions.

The most common cause of unilateral diaphragmatic paralysis is invasion of the phrenic nerve. malignant tumor lung or mediastinum. Accidental damage to the nerve occurs during surgery, trauma, or disruption of its function as a result of a viral infection. Operations specifically aimed at creating unilateral paralysis of the diaphragm in tuberculosis (frenicotomy, frenitripsia, frenicoexeresis, frenicoalcoholization) are currently practically not used. Bilateral diaphragmatic paralysis usually results from a lesion cervical region spinal cord. Cold damage to both phrenic nerves has been described during local cooling of the heart during intracardiac interventions. Paralysis of the diaphragm leads to a sharp one- or two-sided reduction lung volumes and corresponding disruption of ventilation.

Unilateral paralysis of the diaphragm usually does not cause symptoms or is manifested by a decrease in tolerance to significant stress. With bilateral paralysis, shortness of breath is noted with the participation of auxiliary muscles in breathing. Respiratory failure worsens in a horizontal position, when the diaphragm rises even higher. In this case, the paradoxical movement of the anterior abdominal wall, sinking during inspiration. Fluoroscopy reveals a high position of the dome(s) of the diaphragm, immobility or paradoxical rise during inspiration, especially when the upper respiratory tract is closed. Functional study with bilateral paralysis, it reveals a sharp decrease in the total volume and vital capacity of the lungs and additional inspiratory volume; with one-sided - the corresponding volumes are reduced by only 20-25%. In the patient's lying position, volumetric indicators further deteriorate.

Treatment and prognosis Diaphragmatic paralysis depends on its causes. Unilateral paralysis special treatment not required. For bilateral paralysis associated with spinal cord lesions, continuous electrical stimulation of one of the phrenic nerves in the neck using an implantable stimulator is recommended. Nerve lesions associated with viral infection or cold injury during cardiac surgery often resolve spontaneously after 6-8 months.

Relaxation of the diaphragm (idiopathic relaxation of the diaphragm, eventration of the diaphragm) is rare birth defect consisting of underdevelopment of the diaphragmatic muscle; It occurs more often in men, it can be one- or two-sided, and relaxation on the left is usually total, and on the right - partial. Ventilation disturbances are similar to those with diaphragmatic paralysis. The more common unilateral relaxations are almost asymptomatic. X-ray reveals a high position of the dome(s) of the diaphragm, and on the right, partial relaxation, filled by the bulging dome of the liver, sometimes requires differentiation with a tumor (diaphragm, lung, liver). The diagnosis is clarified using pneumoperitoneum, in which the protruding part of the dome is contrasted with air.

Treatment for unilateral lesions is most often unnecessary, although operations have been described that reduce the area of the relaxed dome of the diaphragm and increase the volume of the corresponding hemithorax (diaphragm appliqué, plastic surgery with synthetic tissue). Total bilateral relaxation is apparently incompatible with life, and its treatment has hardly been developed.

Hernias of the natural openings of the diaphragm ( hiatus, holes of Morgagni and Bochdalek) rarely cause severe ventilation problems. Gastroesophageal reflux, characteristic of sliding hernias esophageal opening, can cause repeated aspiration of gastric contents, especially at night, and is related to the pathogenesis of acute and chronic bronchopulmonary diseases, including bronchial asthma. Surgical treatment of these hernias (Nissen operation) in some cases has a beneficial effect on the course of pulmonary pathology.

Congenital defects (false hernia) of the diaphragm in newborns, observed more often on the left, cause massive displacement abdominal organs into the pleural cavity, compression collapse of the lung and displacement of the mediastinum to the opposite side, which causes acute respiratory failure, manifested by severe shortness of breath, cyanosis and motor restlessness child. The diagnosis is confirmed by X-ray examination, in which in the left pleural cavity the stomach and intestinal loops distended with gas are revealed, and the mediastinum is shifted to the right. The situation requires immediate surgical intervention aimed at restoring the continuity of the diaphragm dome.

Traumatic ruptures (false hernias) of the diaphragm are observed with thoracoabdominal injuries, as well as with closed injuries (compression of the chest, abdomen, fall from a height). They are more often observed on the left, since on the right the liver plays the role of a pilot. With massive ruptures as a result of movement of the abdominal organs into the pleural cavity, acute respiratory disorders as a result lung collapse and mediastinal displacement (shortness of breath, cyanosis, tachycardia, etc.). Small ruptures, especially with severe combined trauma, often remain unrecognized. A small volume of abdominal organs initially displaced through a defect in the diaphragm may not have a significant effect on ventilation, and only in case of strangulation in the defect, when the volume hollow organs located in the pleural cavity increases sharply, they may, along with acute side effects gastrointestinal tract(acute pain in the right hypochondrium, vomiting, collapse), severe ventilation disturbances are observed (shortness of breath, cyanosis, hypoxemia).

In any case, a traumatic defect of the diaphragm is an indication for urgent or elective surgery, aimed at its elimination after reduction of the abdominal organs.

Of great importance in obstructive pulmonary pathology is the sharp flattening of the diaphragm during emphysema, associated with an increase in lung volume and an increase in intrathoracic pressure due to the disappearance of elastic retraction of the lungs and valvular disorders of bronchial patency. When contracted, the flattened diaphragm is not able to increase the intrathoracic volume and, moreover, does not lift, but contracts the lower ribs to which it is attached and, thus, prevents inhalation. This phenomenon is observed in the terminal phases of respiratory failure, and its impact appears problematic.

The so-called flutter of the diaphragm (diaphragmatic myoclonus, Leeuwenhoek's syndrome) is an extremely rare disorder characterized by paroxysmal, frequent (about 100 per minute) contractions of the diaphragm, as if superimposed on its respiratory excursions. During attacks, shortness of breath, a twitching sensation in the lower part of the chest and visible pulsation in the eye are noted. epigastric region. The frequency of attacks is reduced by taking antihistamines.

- 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 chest cavity. The only way treatment 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 thoraco-abdominal barrier is often caused by a violation of the development of the organ during prenatal period. Another common cause is paralysis of the diaphragmatic muscles. Highlight the following groups etiological factors leading to relaxation of the diaphragm vault:

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. There are inflammatory and traumatic nature. There is independent inflammation (diaphragmatitis) and secondary damage to the 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 when various kinds disorders of the innervation of the diaphragm. Traumatic processes, including surgical interventions, lead to nerve damage. Total paralysis is caused by severe systemic neurological diseases(poliomyelitis, syringomyelia). Local lesions arise 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 of varying degrees of severity is observed. 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 chest area.

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 the unstable, mild symptoms of the disease.
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, 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, or 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 big pieces 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 gangrene of the stomach.

Diagnostics

If relaxation of the diaphragmatic dome is suspected diagnostic search a surgeon is involved. When interviewing the patient, he clarifies the history of injuries and operations in the chest and abdomen, inflammatory processes lungs, pleura, mediastinum, upper floor of the 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. There is a positive Hoover's sign - elevation of one of the costal arches and outward displacement during deep inspiration.
Percussion. The upward expansion of Traube's subphrenic space is determined. Bottom line The lung is located at the level of the II-IV rib along the anterior surface of the 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, splashing noise.
Functional studies. Spirometry makes it possible to identify restrictive dysfunctions external respiration, 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 of 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 latent form diseases and blurred clinical picture are subject to dynamic observation. They are advised to avoid excessive physical activity, eat often in small portions, avoid overeating. With the progression of the process, the presence of pronounced cardiovascular, respiratory or dyspeptic disorders shown 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 full 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. Prevention of injuries, diagnosis and adequate treatment of inflammatory processes of the pulmonary parenchyma, pleura, mediastinum, drainage subphrenic abscesses help to avoid acquired diaphragmatic paralysis.

Surgical diseases of the diaphragm include a number of pathological processes such as:

I. Sharp closed or open damage diaphragms;

P. Traumatic paresis of the diaphragm;

Sh. Diaphragm hernia;

ІY. Relaxation of the diaphragm.;

Y. Tumors and cysts of the diaphragm;

YІ. Foreign bodies of the diaphragm.

YP. Diaphragmatitis;

YSH. Elevation of the diaphragm;

I. Acute closed or open damage to the diaphragm -

Let us touch upon the practical significance of these pathological processes, due to the frequency of their occurrence and the danger of possible complications.

May occur under conditions closed injury, as a result of a strong blow, sudden compression of the chest or abdominal cavity, followed by rupture of the dome of the diaphragm. In addition, they can be the result of penetrating thoracoabdominal wounds. More often detected during X-ray examination, prolapse is detected abdominal organs into the chest cavity, or during surgical restoration of another abdominal or thoracic organ damaged by trauma. The diaphragm defect is sutured. Sometimes an acute rupture of the diaphragm is not diagnosed and then becomes the cause of chronic post-traumatic diaphragmatic hernia. We will return to them later.

P. Traumatic paresis of the dome of the diaphragm –

The high position of one of the domes of the diaphragm is a consequence of traumatic damage to the phrenic nerve.

Clinically – shortness of breath, cough, hiccups, chest pain on the corresponding side.

There is a history of trauma.

X-ray shows a high position of the corresponding dome of the diaphragm with limited mobility.

Unlike the “true” relaxation of the diaphragm, the dome - not thinned. In some cases, over time, his normal standing and mobility are restored independently or under the influence of conservative treatment, including physical therapy.

Sh. Diaphragm hernia.

Diaphragmatic hernias are the most common pathology of the abdominal obstruction.

All diaphragmatic hernias are divided according to etiology into:

Traumatic

Non-traumatic.

By the presence or absence of a hernial sac on:

True.

By localization:

Hernia of the diaphragm

Hernias of the natural openings of the diaphragm.

Clinical manifestations of diaphragmatic hernia depend on 3 main factors:

1. Compression and bending of the abdominal organs in the hernial orifice, which prolapsed through a defect in the diaphragm into the chest cavity.

2. Compression of the lung and displacement of the mediastinum by prolapsed abdominal organs.

Violation of the function of the diaphragm itself.

Therefore, all symptoms of diaphragmatic hernia can be divided into:

1. Abdominal, associated with disruption of the activity of displaced abdominal organs (pain in the upper abdominal cavity, vomiting, bloating, dysphagia, heartburn, etc.).

2. Cardiorespiratory, depending on compression of the lungs and displacement of the heart (pain in the corresponding side of the chest, shortness of breath, etc.).

Traumatic diaphragmatic hernia -

In the vast majority of these cases, we are talking about the movement of certain abdominal organs through a defect in the diaphragm to the right or, more often, to the right left half chest cavity in different terms after injury. Anamnesis is very important for verifying the diagnosis, in particular a report of the fact of injury and its nature. Distinguish undisadvantaged And disadvantaged traumatic diaphragmatic hernia. A feature of this type of hernia is the fact that over time, most of them infringed and the doctor must always remember this.

More often – traumatic diaphragmatic hernias are “false”, i.e. do not have a hernial sac.

Often during an operation on the abdominal cavity, due to an acute open or closed injury, the surgeon, while eliminating damage to any organ, does not notice a defect in the diaphragm, where over time the stomach, intestinal loops, greater omentum, and in case of large defects, even everything these organs together. In these cases, the patient is discharged from the hospital, and the documents do not indicate an existing defect in the diaphragm, and later, when, against the background of almost complete well-being, an attack of severe pain in the chest and abdominal cavities suddenly develops, as well as a picture of high or low gastrointestinal obstruction - diagnosis may be difficult, and the operation may be delayed.

According to clinical symptoms, a strangulated traumatic diaphragmatic hernia may resemble thrombosis of mesenteric vessels, strangulated intestinal obstruction, etc.

The diagnosis is made based on the clinical picture, anamnesis and x-ray data.

During survey fluoroscopy and radiography of the chest and abdominal organs, there is a violation of the mobility of the corresponding dome of the diaphragm, the presence of intestinal loops overinflated with gas, darkening in the corresponding half of the chest, a decrease in the corresponding pulmonary field (right or left), a shift of the mediastinum to the opposite side, and with a defect of the left dome, the presence of fluid levels in the abdominal and left half of the thoracic cavities is determined. The next stage of diagnosis is contrasting the stomach with a barium suspension (per os), passage of barium through the intestines and contrasting the colon by introducing contrast into it (per clizma).

Computed tomography can also be used for diagnosis. Treatment is only surgical and as early as possible. In case of an attack of pain, in order to decompress the stomach, it is necessary to insert a transnasal probe into it to decompress this organ. The operation consists of freeing the abdominal organs that have prolapsed into the chest cavity from the adhesions, bringing them down into the abdominal cavity and suturing the diaphragm defect. In case of necrosis of part of the intestine or omentum, their resection is performed. Access is transthoracic, supplemented by laparotomy if necessary.