DIAPHRAGMATIC HERNIAS Maureen Austin Kimberly Novak

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DIAPHRAGMATIC HERNIASMaureen
Austin Kimberly Novak
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Types of Hernias

• Diaphragmatic
• Hiatal
• Umbilical

• Inguinal
• Femoral
• Perineal

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Diaphragmatic Hernia

• A rent in the diaphragm that allows herniation of
  of abdominal viscera into the thoracic cavity.

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Diaphragmatic Hernias can either be Congenital or
Acquired
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Traumatic Diaphragmatic Hernia

• A common outcome of blunt force trauma to the
  thoracic cavity
• Dogs vehicle trauma, kicked by horse/cow
• Cats high rise trauma, vehicle trauma
• Liver is the most commonly herniated
• Young males at greatest risk- another
  good reason to castrate!!!!

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Congenital Diaphragmatic Hernia

• Pleuroperitoneal Diaphragmatic Hernia
• Uncommon autosomal recessive trait
• Incomplete or failed fusion of pleuroperitonel
  membrane
• Failure of pleuroperitoneal folds to incorporate
  muscle
• Located dorsolateral those on left often result
  in still birth or neonatal death
• Stomach, spleen and small intestine most common

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Congenital Diaphragmatic Hernia

• Pericardioperitoneal Diaphragmatic Hernia (PPHD)
• Very common CATS
• Often incidental CATS
• Not inherited, 58 males
• Weimeraners predisposed (Conformation???)
• Liver, omentum, spleen, falciform ligament
  common- NOT STOMACH

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PPHD

• Always congenital, most common congenital
  diaphragmatic hernia
• Diaphragm and pericardium not continuous
• Failure of septum transversum differentiation
  teratogens, genetic defect, prenatal trauma
• Ventral diaphragm
  

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Associated Abnormalities

• Sternal defects/Pectus excavatum
• Cranial midline abdominal wall hernia
• Umbilical hernia
• Cardiac defects (VSD)
• PSS
• Pulmonary vascular disease

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Diagnostic Dilemma

• 20 traumatic diagnosed _at_ 4 weeks post
  traumaomentum plug, rent w/no hernia, failure
  to dx
• 48 PPHD lt 1y 36_at_ 1-4y
• May not be until as old as 14y
  omentum plug formed, but weak diaphragm,
• often incidental-no symptoms

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Clinical Signs

• Asymptomatic ? Gravely Ill

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Clinical Signs

• Respiratory signs gt GI signs
• Dyspnea, tachypnea, coughing
• Pleural effusion, pericardial effusion
• Vomiting, gagging , diarrhea
• Auscultation and Palpation helpful
• Rare encephalopathy
• Shock (both acquired and congenital)
• Concurrent injuries/congenital defects

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How Do You Diagnose a Diaphragmatic Hernia?

• What you do first is going to depend on your
  history and physical examination
• Is there history of trauma?
• Respiratory problems?
• Do you hear borborygmi on thoracic auscultation?
• The tools used to diagnose a diaphragmatic
  hernia are the same for each type. The results
  obtained from your diagnostics will be different
  depending on the type of hernia you have.

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Most often you will be using an imaging modality
to confirm a diagnosis of diaphragmatic hernia

• Survey radiographs
• Gastrogram (upper GI series)
• Positive contrast celiography

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Survey Radiographs

• Signs of a traumatic hernia
• Loss of the diaphragmatic shadow
• Presence of abdominal viscera in the thoracic
  cavity i.e. a radiolucent gas filled structure
• Cranial and /or lateral displacement of the
  heart and lungs due to abdominal viscera pushing
  on them
• Cranial and /or lateral displacement of the
  stomach or intestines within the abdominal cavity
  due to liver herniation

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Survey Radiographs cont...

• Signs of pericardioperitoneal hernia
• Enlarged, globoid cardiac silhouette
• Tubular gas shadows within the pericardium
• Loss of a distinct ventral border of the cupula
  of the diaphragm without there being pleural
  fluid
• A mesothelial remnant between the heart and the
  diaphragm
• The appearance of a small liver or cranial
  displacement of the stomach suggesting herniation
  of the liver

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Gastrogram (Upper GI series)

• This positive contrast study will give you a
  definitive diagnosis of diaphragmatic hernia if
  the stomach or intestines are herniated into the
  thoracic cavity
• Barium sulfate or a water soluble iodinated
  positive contrast medium is given by orogastic
  intubation and then radiographs are taken
• Remember though that if you do not see any
  herniated organs in the thoracic cavity filled
  with the contrast solution it does not mean that
  you do not have a DH. You could either have no
  organs herniated through or a non-GI organ is
  herniated (spleen).

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Positive Contrast Celiography

• This procedure is usually done if survey
  radiographs or an upper GI study fail to give you
  an unequivocal diagnosis
• A water soluble iodinated contrast medium is
  injected through a catheter into the peritoneal
  cavity just to the right of midline and cranial
  to the umbilicus.
• If there is a defect in the diaphragm then the
  contrast material will enter into the pleural or
  pericardial space depending on the type of hernia
• However, you can get a false negative with this
  test if the defect in the diaphragm is covered up
  by the omentum

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Treatment

• The definitive treatment for any of the hernias
  described is surgical repair of the defect in the
  diaphragm and replacement of any abdominal
  viscera that was herniated back into the thoracic
  cavity
• Patients with traumatic hernias are first
  stabilized and rested before proceeding with
  surgery unless life-threatening hypoventilation,
  caused by abdominal viscera compressing the
  lungs, occurs

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Treatment cont..

• In the pericardioperitoneal hernia repair closing
  of the defect in the diaphragm will also
  simultaneously close the opening to the
  pericardial sac since the two are conjoined
  together
• Air within the thoracic cavity should be
  released by means of thoracentesis or a tube
  thoracostomy

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The case of the coughing cat

• Chelsea
• 13 year old spayed female Burmese
• Presented March 22, 2002 with a
• history of intermittent gagging/retching and
  occasional vomiting with no pattern of occurrence
• Owner acquired the cat in may 1999 after the
  previous owners had decided to euthanize Chelsea
  due to erratic episodes of severe illness that
  could never be explained and would seem to just
  go away on its own
• Chelsea was up to date on all vaccines and was
  on revolution for heartworm and flea
  preventative.

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Physical exam findings

• Temp normal
• Pulse- 200beats per minute
• Respiratory rate- 50 breaths per minute
• weight- 7.1 lbs
• Upon auscultation increased lung sounds were
  heard bilaterally
• Abdominal palpation yielded a cough from Chelsea
  and tracheal palpation also caused her to begin
  gagging with an increase respiratory effort

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• Rule outs
• Feline asthma
• Upper Airway disease
• Tracheal abnormalities

• Diagnostics
• Survey thoracic and abdominal radiographs
• CBC and Chem profile
• Fecal
• Urinalysis

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• Fecal results
• Normal
• Chem profile results
• Creatinine 2.8 (0.7 2.2)
• BUN 36 (18 41)
• Total Protein 10.4 (5.5 7.7)
• CBC results
• Normal
• Urinalysis
• Normal

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• Survey radiographic report
• Liver present in the cranial abdomen and shaped
  oddly
• Caudal portion of the right side of thorax
  appears to be occupied by a well marinated gas
  filled structure
• A stomach shadow is not seen in the normal
  position in the abdomen and the colon is
  excessively far cranial in the abdominal cavity
• A dense bronchial and interstitial lung pattern
  is seen
• Kidneys appear to be small
• Recommended to do a positive contrast shallow

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• Gastrogram results
• Results consistent with herniation of the stomach
  in the thoracic cavity therefore diagnosing a
  diaphragmatic hernia
• There was no evidence of any abdominal viscera
  within the pericardial sac or of a connection
  between the diaphragm and the pericardium

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What do we do now?

• Chelsea was scheduled for diaphragmatic hernia
  repair the next morning
• A perforation was found in the diaphragm located
  on the midline, dorsal to the liver, that
  measured approximately two and one half inches in
  length. The edges of the hernia were smooth and
  the tissue was healthy
• The stomach and part of the spleen had herniated
  into the thoracic cavity and were pulled through
  the hole and placed back into their normal
  positions. Both organs looked normal
• There were no adhesions and the pleura of the
  thorax was intact
• There was no evidence of a connection between
  the pericardium and diaphragm

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Post-surgery

• Chelsea did not need any additional medications
  after surgery other than pain medication
• Exercise was to be limited for 10 days post op
  to prevent her incision from becoming infected

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So how did this happen to Chelsea?

• There was no history of trauma
• Records obtained from the previous owners showed
  instances where Chelsea became violently ill and
  then would have regression of clinical signs
• She was referred to MSU prior to the exchange in
  ownership but no radiographs were taken at that
  time

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Diagnosis

• Chelsea was diagnosed with a congenital
  pleuroperitoneal diaphragmatic hernia
• While this type of hernia is very rare, it most
  common to see the stomach, spleen, and small
  intestine through a left dorsolateral diaphragm
  defect
• It was believed that this was not a traumatic
  hernia due to the fact that there were no
  adhesions within the thoracic cavity, the pleura
  was intact, and all organs were completely normal
  in appearance
• Chelsea's hernia was present at birth and over
  the years grew in size until abdominal viscera
  were able to pass through.
• Her intermittent gagging/vomiting was probably
  caused by the stomach and spleen pushing on her
  lungs and heart

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The End
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References
Biery DN., Owens JM. Radiographic Interpretation
for The Small Animal Clinician 2nd Edition.
Baltimore Williams Wilkins. 1999.   Birchard
SJ., Sherding RG. Saunders Manual of Small
Animal Practice 2nd Edition. New York WB
Saunders Co. 2000.   Ettinger, SJ., Feldmen
E.C. Textbook of Veterinary Internal Medicine
5th Edition. New York WB Saunders Co.
2000.   Hoskins, JD. Veterinary Pediatrics Dogs
and Cats from Birth to Six Months. New York WB
Saunders Co. 2001. Norden, DM., Lahunta, Ad.
The Embryology of Domestic Animals
Developmental Mechanisms and Malformations.
Williams and Wilkins 1985.