Paralysis of the diaphragm symptoms. What is diaphragm dome relaxation and what are its consequences? I

Paralysis and paresis of the diaphragm

Diaphragm paralysis is characterized by its high standing and lack of respiratory movements. Unlike a hernia, there is no hernial orifice or sac. The musculoskeletal component was preserved throughout (especially in the early stages of the disease), when its atrophy had not yet begun.

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

Approximately 5% of newborns who have undergone neonatal trauma have diaphragmatic paresis of varying degrees, which in most cases is combined with Erb's palsy. In infants and older children, diaphragmatic paresis 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 in empyema various origins, tumor lesions.

Clinic and diagnostics

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

The diagnosis can only be made by X-ray examination. Characteristic is the high standing of the dome of the diaphragm, its contour has a clear hemispherical shape, the mediastinal organs are displaced to the healthy side. Synchronous respiratory movements the diaphragm is absent, 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, adequate pulmonary ventilation. In addition to constant oxygenation, breathing is periodically carried out with increased resistance on exhalation.

If there is no effect, an auxiliary or artificial respiration. Provide stimulation to improve recovery processes, muscle trophism and conduction nerve impulses. Be sure to use cervical electrophoresis with prozerin, aloe, lidase, prescribe vitamins and anticholinesterase drugs (prozerin).

If there is no effect after 2-3 weeks, apply surgery, which consists in performing a thoracotomy and applying mattress gathering sutures in such a way that a flattening of the dome of the diaphragm occurs. At the same time, it must be remembered that the phrenic nerve and its main branches should not get into the seams, 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 the operation, the condition of children begins to improve rapidly.

Foreign bodies of the trachea and bronchi

Foreign body aspiration (FB) in children is quite common. All researchers note that this species 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 survey statistics, the frequency of aspiration of foreign bodies is 3.7 per 1000 children. It should be noted that all over the world, otolaryngologists deal mainly with this pathology in children and, as a rule, only in acute period(during the day) after aspiration IT. This circumstance explains the significant frequency of unnoticed aspirations, especially in young children.

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

through or partial;
valve;
complete

All children with late dates diagnosis of IT of the tracheobronchial tree, partial obstruction is noted, which determines the possibility of long-term carriage of IT. Most IT (mainly of organic origin) is eliminated due to coughing or the action of mucociliary transport, but some are delayed 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 can also be observed, which also affects the clinical symptoms. Complete blockage of the bronchus can lead to atelectasis of the segment or lobe ventilated by this bronchus. Obturation of the trachea causes an acute attack of suffocation, which, if not provided timely help can lead to serious complications, including death.

However, IT may not completely obstruct the airways, leading to a partial violation of ventilation in this area, or creating a valvular mechanism with the subsequent development of emphysema, which captures various volumes of the affected lung. Clinical and radiological characteristic, of course, depends on the period that has elapsed since the aspiration of IT. auscultatory there is a weakening of breathing, wheezing of various nature, as well as uncharacteristic respiratory noises. In children with early dates from the moment of aspiration to radiographs revealed:

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

Very effective method research for suspected aspiration of IT is chest x-ray with the detection of pathological mobility of the median shadow (positive symptom of Goltznecht-Jacobson).

Treatment

The main method of treatment is endoscopic extraction foreign body using a rigid respiratory bronchoscope with optical forceps with various shapes of working parts. Only in rare cases in case of failure of bronchological removal of a foreign body, due to the nature of IT or the development of suppuration, one has to resort to thoracotomy with bronchotomy or resection of the interested area of the lung.

Bychkov V.A., Manzhos P.I., Bachu M. Rafik Kh., 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. It occurs due to anomalies in the development of the fetus or due to pathological process, which 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 due to the progressive protrusion of one of the domes of the organ.

A congenital anomaly of development is characterized by the fact that one of the domes is devoid of muscle fibers. It is thin, transparent, consists mainly of sheets of the pleura and peritoneum.

In the case of acquired relaxation we are talking about paralysis of muscles and their subsequent atrophy. In this case, two variants of the development of the disease are possible: the first is a lesion with a complete loss of tone, when the diaphragm looks like a tendon sac, and muscle atrophy is quite pronounced; the second - violations of 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

A congenital form of relaxation can be provoked by abnormal laying of diaphragm myotomes, as well as impaired muscle differentiation, and intrauterine injury/aplasia of the phrenic nerve.

Acquired form ( secondary atrophy muscles) can be caused by inflammatory and traumatic injuries of the organ.

Also, an acquired ailment occurs against the background of damage to the phrenic nerve: traumatic, surgical, inflammatory, scar damage with lymphadenitis, tumor.

The 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 manifest itself both in the early childhood, as well as 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 one not by the absence, but by paresis / paralysis of the 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 an organ injury.

Stretching of the stomach with pyloric stenosis can provoke the disease: constant trauma from the stomach provokes degenerative changes in the muscles and their relaxation.

Symptoms

The manifestations of the disease may differ from case to case. For example, they are very pronounced in congenital pathology, and in acquired, especially partial, segmental, they may be completely absent. This is due to the fact that the acquired is characterized by a lower degree of tissue stretching, a lower standing of the organ.

In addition, the segmental localization of the pathology on the right is more favorable, since the adjacent liver, as it were, tampons the damaged area. Limited relaxation on the left can also be covered by the spleen.

With diaphragm relaxation, symptoms rarely occur in childhood. The disease often manifests itself in people 25-30 years old, especially in those who are engaged in heavy physical labor.

The main cause of complaints is the displacement of the peritoneal organs into the chest. For example, a 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 disturbed, respectively, pain occurs. The kinking of the veins can lead to internal bleeding. These signs of the disease are aggravated after a meal and physical activity. In this situation pain syndrome provokes an inflection 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. It ends just as quickly as it starts. Nausea often precedes an attack. It is noted that the pathology may be accompanied by difficulty in passing food through the esophagus, as well as bloating. These two phenomena quite often occupy a leading place in the clinic of pathology.

Most patients complain of attacks of pain in the region of the heart. These can be due to 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 there is a suspicion of a hernia, but it is almost impossible to make 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 physician, performing a physical examination, discovers the following phenomena: the lower border of the left lung is shifted upward; the zone of subdiaphragmatic tympanitis extends upwards; in the area of pathology, intestinal peristalsis is heard.

treatment

In this situation, only one way to eliminate the disease is possible - surgical.

However, not all patients are operated on. To do so, evidence is needed.

Surgical intervention is carried out only in cases where a person has pronounced anatomical changes, clinical symptoms disable, cause severe discomfort.

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The worst Best

The diaphragm is the main muscle that provides pulmonary ventilation, and its value can be compared to a certain extent with the value of the cardiac muscle that carries out blood circulation. Decompensation of the function of the diaphragm is essential mechanism thanatogenesis in patients dying from respiratory failure for acute or chronic pathology lungs. However, in this chapter, only those ventilation disorders that arise as a result of the pathology of the diaphragm itself will be considered. These pathologies include diaphragmatic paralysis, relaxation of the diaphragm, diaphragmatic hernia various genesis and some other states.

The most common cause of unilateral diaphragmatic paralysis is phrenic nerve invasion. malignant tumor lung or mediastinum. There is accidental damage to the nerve during surgery, trauma, or a violation of its function as a result of a viral infection. Operations specifically aimed at creating unilateral paralysis of the diaphragm in tuberculosis (phrenicotomy, frenitripsy, phrenic exeresis, phrenic alcoholization) are practically not used at present. Bilateral diaphragmatic paralysis is usually the result of a lesion cervical spinal cord. Cold injuries of both phrenic nerves during local cooling of the heart during intracardiac interventions are described. Paralysis of the diaphragm leads to a sharp unilateral or bilateral decrease in lung volumes and the corresponding lack of ventilation.

Unilateral diaphragmatic paralysis usually causes no symptoms or is manifested by a decrease in tolerance to significant loads. With bilateral paralysis, shortness of breath is noted with the participation of auxiliary muscles in breathing. Respiratory failure is aggravated in a horizontal position, when the diaphragm rises even higher. In this case, the paradoxical movement of the anterior abdominal wall sinking during inhalation. Fluoroscopy reveals a high standing dome(s) of the diaphragm, immobility, or a paradoxical rise during inhalation, especially when the upper airway is closed. functional research 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 position of the patient lying down, volume indicators further worsen.

Treatment and prognosis diaphragmatic paralysis depends on its causes. Unilateral paralysis special treatment do not require. For bilateral paralysis associated with spinal cord injury, permanent electrical stimulation of one of the phrenic nerves in the neck with an implantable pacemaker 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 in the underdevelopment of the diaphragmatic muscle; occurs more often in men, it is one- or two-sided, and relaxation is usually total on the left, and partial on the right. Ventilation disturbances are similar to those in diaphragmatic paralysis. The most common unilateral relaxations are almost asymptomatic. Radiologically, a high standing dome (domes) of the diaphragm is detected, and on the right, partial relaxation, filled with a protruding dome of the liver, sometimes requires differentiation with a tumor (diaphragm, lung, liver). The diagnosis is specified with the help of pneumoperitoneum, in which the protruding part of the dome is contrasted with air.

Treatment for unilateral lesions is most often unnecessary, although operations are described that reduce the area of the relaxed dome of the diaphragm and increase the volume of the corresponding hemithorax (diaphragmatic application, plastic with synthetic fabric). Total bilateral relaxation, apparently, is not compatible with life, and its treatment is almost not developed.

Hernias of the natural openings of the diaphragm ( esophageal opening, openings of Morgagni and Bochdalek) rarely cause severe ventilation disorders. Gastroesophageal reflux characteristic of sliding hernias esophageal opening, may cause re-aspiration of gastric contents, especially at night, and be related to the pathogenesis of acute and chronic bronchopulmonary diseases, including bronchial asthma. Surgical treatment of these hernias (Nissen's operation) in some cases favorably affects the course of pulmonary pathology.

Congenital defects (false hernias) 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 in the opposite direction, which causes acute respiratory failure, manifested by severe shortness of breath, cyanosis and restlessness child. The diagnosis is confirmed by X-ray examination, in which the left pleural cavity the stomach and intestinal loops are revealed, and the mediastinum is displaced to the right. The situation requires immediate surgical intervention aimed at restoring the continuity of the dome of the diaphragm.

Traumatic ruptures (false hernias) of the diaphragm are observed with thoracoabdominal wounds, as well as with closed injuries (compression of the chest, abdomen, fall from a height). More often they are observed on the left, since the liver plays the role of a pelota on the right. With massive ruptures as a result of the 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 tears, especially in severe concomitant trauma, often go 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 if it is infringed in the defect, when the volume hollow organs, located in the pleural cavity, increases sharply, can, along with acute phenomena from the side gastrointestinal tract(acute pain in the right hypochondrium, vomiting, collapse), there are pronounced ventilation disorders (dyspnea, cyanosis, hypoxemia).

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

Of great importance in obstructive pathology of the lungs is a sharp flattening of the diaphragm in 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. A flattened diaphragm during contraction is not able to increase the intrathoracic volume and, moreover, does not lift, but tightens the lower ribs, to which it is attached and, thus, prevents inhalation. This phenomenon is observed in the terminal phases of respiratory failure, and the impact on it seems problematic.

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

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

ICD-10

J98.6 Diaphragm disease

General information

Relaxation of the diaphragm (paralysis of the diaphragm, megaphrenia, primary diaphragm) is due to sharp dystrophic changes the muscular part of the organ or a violation of its innervation. It can be congenital or acquired. Complete (total) relaxation of the 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, violations are formed gradually as a person grows and under the influence external factors. The first symptoms appear at the age of 25-30. More often suffer men engaged in heavy physical labor.

Causes of diaphragm relaxation

A pronounced thinning, up to the complete absence, of its muscle layer leads to a high standing of the diaphragmatic dome. This structure of the thoracic obstruction is more often due to a violation of the development of the organ during prenatal period. Another common cause is paralysis of the diaphragmatic muscles. Allocate following groups etiological factors leading to relaxation of the arch of the diaphragm:

Embryogenesis disorders. These include defects in the laying 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 malformations. internal organs.
Damage to the diaphragmatic muscle. It is inflammatory and traumatic nature. Distinguish between independent inflammation (diaphragmatitis) and secondary damage to the diaphragm. The latter appears when the pathological process spreads from adjacent organs, for example, with subdiaphragmatic abscesses, pleural empyema.
Paralysis of the diaphragmatic dome. Occurs when various kinds violations 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 germination of the tumor of the nerve trunk.

Pathogenesis

At congenital anomaly, leading to relaxation of the thoracic septum, is detected practically complete absence muscle tissue. The thin diaphragm consists of pleural and peritoneal sheets. With acquired pathology, muscle dystrophy of varying 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 side of the lesion, the displacement of the mediastinum in the opposite direction. Relaxation of the left dome lifts up the abdominal organs. There are torsion of the stomach, splenic flexure of the colon. The esophagus kinks, blood vessels pancreas and spleen, leading to transient organ ischemia. Due to violation venous outflow veins of the esophagus dilate, bleeding occurs. Relaxation of the right dome (usually partial) causes local deformation of the liver.

Classification

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

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

Diaphragm Relaxation Symptoms

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

Respiratory disorders are manifested by bouts of shortness of breath and dry, unproductive, painful cough with little physical exertion, changes in body position, after eating. A clear relationship of symptoms with food intake is a pathognomonic sign of diseases of the diaphragmatic dome. Cardiac activity suffers. There is tachycardia, disturbances in the rhythm of the heart and a feeling of palpitations. Periodically, the patient is disturbed by retrosternal pain of a pressing, squeezing nature, reminiscent of cardialgia in angina pectoris.

Digestive disorders are the leading signs of diaphragm pathology. Seizures acute pain in the epigastric region, right or left hypochondria also occur after eating. Pain are quite intense, last from 20-30 minutes to 2-3 hours, then stop on their own. When the esophagus is kinked, swallowing is disturbed. In some cases, the patient is able to swallow big chunks solid food, and chokes on liquid (paradoxical dysphagia). Patients often complain of heartburn, hiccups, belching, nausea, less often 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 abdominal obstruction can reach the level of the second rib. In this case, a pronounced displacement of the internal organs occurs. The lung is compressed, areas of atelectasis are formed. The stomach and intestines pulled up take the wrong position. Because of this, they develop severe complications from the digestive organs. The most frequent of them are torsion of the stomach, intestines, ulcerative processes, bleeding. Leading surgeons describe isolated cases gangrene of the stomach.

Diagnostics

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

Inspection. Sometimes it is possible to visually determine the paradoxical movement of one of the diaphragmatic domes. The diaphragm rises during inspiration and falls during expiration. There is a positive symptom of Hoover - the rise of one of the costal arches and displacement outward with a deep breath.
Percussion. The extension upwards of Traube's subdiaphragmatic space is determined. Bottom line lung is located at the level of II-IV ribs along the anterior surface of the chest wall. The boundaries of absolute and relative cardiac dullness are shifted in the opposite direction.
Auscultation. In the basal parts of the lungs, weakened breathing is heard. Auscultation of the heart reveals muffled tones, increased heart rate, rhythm disturbance. In the lower part of the chest in front you can hear intestinal peristalsis, splash noise.
Functional Research. Spirometry makes it possible to detect restrictive dysfunctions external respiration significant decrease in lung capacity. On the ECG, a slowdown in intraventricular conduction, extrasystole, signs of myocardial ischemia are determined.
Radiation diagnostics. X-ray and CT of the chest are the most informative methods diaphragm research. The radiograph visualizes the high location of one of the domes (level II–V of the rib). X-ray reveals paradoxical movement of the diaphragmatic vault. The use of contrast allows you to identify the kinks of the esophagus, stomach, displacement of the digestive organs upward. CT most accurately determines the degree of relaxation, helps to recognize the secondary pathology of the 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 arches 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 surgery. Patients with latent form diseases and an erased 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 surgical intervention. Relaxation of the diaphragm, complicated by organ rupture, volvulus of the stomach, intestines, bleeding, is subject to emergency surgical correction.

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

Forecast 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 ultrasound procedure reveals the absence of diaphragmatic muscles in the fetus. Identified relaxation must be corrected before the development of complications. Injury prevention, diagnosis and adequate treatment of inflammatory processes in the lung parenchyma, pleura, mediastinum, drainage subphrenic abscesses help to avoid acquired paralysis of the diaphragm.

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

I. Acute closed or open damage diaphragms;

P. Traumatic paresis of the diaphragm;

Sh. Hernia of the diaphragm;

ІY. Relaxation of the diaphragm .;

Y. Tumors and cysts of the diaphragm;

YІ. Foreign bodies of the diaphragm.

YP. Diaphragmatites;

YSh. diaphragm elevation;

I. Acute closed or open damage to the diaphragm -

Let us touch on 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, a sharp compression of the chest or abdominal cavity, followed by a rupture of the dome of the diaphragm. In addition, they may be the result of penetrating thoracoabdominal wounds. More often detected during X-ray examination, its prolapse is detected abdominal organs into the chest cavity, or during the surgical restoration of another abdominal or thoracic organ damaged by trauma. The diaphragm defect is sutured. Sometimes acute diaphragmatic rupture is not diagnosed and then becomes the cause of chronic post-traumatic diaphragmatic hernia. We will return to them.

P. Traumatic paresis of the dome of the diaphragm -

The high standing 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.

History of trauma.

X-ray - high standing of the corresponding dome of the diaphragm with limited mobility.

In contrast to the "true" relaxation of the diaphragm, the dome - not thinned. In some cases, over time, his normal standing and mobility are restored on their own or under the influence of conservative treatment, including physiotherapy.

Sh. Hernia of the diaphragm.

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:

Diaphragmatic hernia

Hernias of the natural openings of the diaphragm.

Clinical manifestations of diaphragmatic hernias depend on 3 main factors:

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

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

Diaphragm dysfunction.

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

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

2. Cardiorespiratory, depending on the compression of the lungs and the 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 left half chest cavity in various terms after injury. The anamnesis is very important for the verification of the diagnosis, in particular, the report on the fact of the injury and its nature. Distinguish unimpaired and disadvantaged traumatic diaphragmatic hernia. A feature of this type of hernia is the fact that over time, most of them infringed upon and the doctor must always remember this.

More often - traumatic diaphragmatic hernia - "false", i.e. do not have a hernial sac.

Often during abdominal surgery, due to an acute open or closed injury, the surgeon, while eliminating damage to any organ, does not notice a diaphragm defect, where over time, the stomach, intestinal loops, greater omentum are introduced, and in case of large defects, even all these organs together. In these cases, the patient is discharged from the hospital, and the documents do not indicate an existing diaphragm defect, 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 - the diagnosis may be difficult and the operation may be belated.

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

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

Plain fluoroscopy and radiography of the organs of the chest and abdominal cavities show 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 lung field (right or left), mediastinal displacement in the opposite direction, and with a defect of the left the dome is determined by the presence of fluid levels in the abdominal and left half of the chest cavities. The next stage of diagnosis is the contrasting of the stomach with a barium suspension (per os), the passage of barium through the intestines and the contrasting of the large intestine, the introduction of contrast into it (per clizma).

Computed tomography can also be used for diagnostics. Treatment is only surgical and as early as possible. In case of an attack of pain, it is necessary to pass a transnasal probe into it in order to decompress the stomach to decompress this organ. The operation consists in releasing 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 a part of the intestine or omentum - their resection. Access - transthoracic, if necessary - supplemented by laparotomy.