Diaphragmatic relaxation is a total or limited relaxation and high standing of the dome of the thoracic septum with the 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 localization and severity of the pathological process. The leading diagnostic methods are X-ray examination and computed tomography of the thoracic cavity. The only method of treatment is auto- or alloplasty of the diaphragmatic dome or its part.
ICD 10
J98.6 Diseases of the diaphragm
Meaning
Diaphragmatic relaxation (paralysis of the diaphragm, megaphrenia, primary diaphragm) is caused by sharp dystrophic changes in the muscular part of the organ or a violation of its innervation. It can be congenital or acquired. Complete (total) relaxation of the thoracic septum is more common on the left. The limited protrusion of its area (diverticulum of the diaphragm) is usually localized in the anterior medial part of the right dome. In children, diaphragmatic relaxation occurs very rarely, disorders form gradually as a person grows and under the influence of external factors. The first symptoms appear at the age of 25-30. Men who are engaged in heavy physical labor suffer more often.
Causes of diaphragmatic relaxation
A pronounced thinning, up to the complete absence, of its muscular layer leads to a high standing of the diaphragmatic dome. Such a structure of the thoracic barrier is more often caused by a violation of the development of the organ in the intrauterine period. Another common cause is paralysis of the diaphragmatic muscles. There are the following groups of etiological factors leading to diaphragmatic relaxation arch:
- Disorders of embryogenesis. This includes defects in the laying of myotomes and further differentiation of muscle elements, underdevelopment or intrauterine damage to the diaphragmatic nerve. Congenital diaphragmatic relaxation is often combined with other malformations of internal organs.
- Damage to the diaphragmatic muscle. It can be inflammatory and traumatic in nature. There are 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, empyema of the pleura.
- Paralysis of the diaphragmatic dome. Occurs with various kinds of 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 (polio, syringomyelia). Local lesions occur as a result of the tumor germination of the nerve trunk.
Pathogenesis
With a congenital anomaly leading to relaxation of the thoracic septum, an almost complete absence of muscle tissue is revealed. The thin diaphragm consists of pleural and peritoneal leaflets. With acquired pathology, muscular dystrophy of varying degrees of severity is observed. The absence of muscle tone leads to the loss of part of the functional abilities of the diaphragmatic arch. Due to the difference in pressure in the thoracic and abdominal cavities, the internal organs stretch the diaphragm, contribute to its complete 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, displacement of the mediastinum in the opposite direction. Relaxation of the left dome lifts up the abdominal organs. There are inversions of the stomach, splenic bending of the colon. There are excesses of the esophagus, blood vessels of the pancreas and spleen, leading to transient ischemia of the organs. Due to a violation of the venous outflow, the 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. According to the time of occurrence and etiological factors, diaphragmatic relaxation is divided into congenital and acquired. The process can be located on the right or on the left, it can be total or partial. Depending on the clinical course , there are 4 variants of diaphragmatic relaxation arch:
- Asymptomatic. There are no manifestations of the disease. Relaxation is detected by chance during chest x-ray.
- With erased clinical symptoms. This form is characteristic of a limited, more often right-sided process. The patient usually does not attach importance to fickle, mild symptoms of the disease.
- With a detailed clinical picture. It manifests itself in a variety of symptoms, depending on the degree of damage to the respiratory, digestive, and cardiovascular systems.
- Complicated. It is characterized by the development of serious complications (inversions, ulcers of the stomach and intestines, gastrointestinal bleeding and others).
Symptoms of diaphragmatic relaxation
Clinical manifestations of relaxation of the diaphragmatic dome are diverse. Symptoms are more pronounced in congenital pathology. Limited relaxation of the diaphragm area may occur latently or with minimal complaints. In the total absence of the tone of the thoracic septum, the disease is accompanied by respiratory, cardiovascular, dyspeptic syndromes. Most patients make general complaints about episodes of weakness, unmotivated weight loss.
Respiratory disorders are manifested by attacks of shortness of breath and dry unproductive painful cough with little physical exertion, changes in body position, after eating. A clear connection of symptoms with food intake is a pathognomonic sign of diseases of the diaphragmatic dome. Cardiac activity suffers. There is tachycardia, heart rhythm disturbances and a feeling of palpitation. Periodically, the patient is disturbed by chest pain of a pressing, compressive nature, resembling cardialgia in angina pectoris.
The leading signs of the pathology of the diaphragm are digestive disorders. Attacks of acute pain in the epigastric region, right or left hypochondria also occur after eating. The pain is quite intense, lasts from 20-30 minutes to 2-3 hours, then it stops on its own. When the esophagus is inflected, swallowing is disrupted. In some cases, the patient is able to swallow large chunks of 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, diaphragmatic relaxation, especially congenital, gradually progresses. The dome of the thoracic barrier can reach the level of the second rib. At the same time, there is a pronounced displacement of internal organs. The lung is compressed, areas of atelectasis are formed. The stomach and intestines, pulled up, occupy the wrong position. Because of this, severe complications develop from the digestive organs. The most frequent of them are stomach and intestinal inversions, ulcerative processes, 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 is engaged in a diagnostic search. Interviewing the patient, he clarifies the presence in the anamnesis of injuries and operations in the chest and abdomen, inflammatory processes of the 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 on exhalation. There is a positive Hoover symptom – the rise of one of the rib arches and the displacement outward with a deep breath.
- Percussion. The upward expansion of the Traube subdiaphragmal space is determined. The lower border of 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 heart dullness are shifting in the opposite direction.
- Auscultation. In the basal parts of the lungs, weakened breathing is heard. During auscultation of the heart, muffling of tones, increased heart rate, rhythm disturbance are detected. In the lower part of the chest from the front, you can hear intestinal peristalsis, the noise of splashing.
- Functional research. Spirometry makes it possible to identify restrictive violations of the function of external respiration, a significant decrease in the vital capacity of the lungs. The ECG determines the slowing of intraventricular conduction, extrasystole, signs of myocardial ischemia.
- Radiation diagnostics. Chest radiography and CT are the most informative methods of examining the diaphragm. The radiograph visualizes the high location of one of the domes (level II–V ribs). During fluoroscopy, a paradoxical movement of the diaphragmatic arch is detected. The use of contrast allows you to identify the excesses of the esophagus, stomach, and the displacement of the digestive organs upward. CT most accurately determines the degree of relaxation, helps to recognize secondary pathology of internal organs.
Complete relaxation of the thoracic barrier should be differentiated with its rupture and diaphragmatic hernias. Sometimes the high standing of one of the arches may hide a basal spontaneous pneumothorax. Partial relaxation often masks neoplastic and inflammatory processes of internal organs, pleura and peritoneum, liver cysts and pericardium.
Treatment of diaphragmatic relaxation
The only method of treating 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 exertion, eat often in small portions, and avoid overeating. With the progression of the process, the presence of pronounced cardiovascular, respiratory or dyspeptic disorders, surgical intervention is indicated. Diaphragmatic relaxation, complicated by organ rupture, inversion of the stomach, intestines, bleeding, is subject to emergency surgical correction.
Taking into account the localization of the pathological process, laparotomy or thoracotomy is performed. Minimally invasive thoracoscopic access has been developed. With moderate relaxation with partial preservation of muscle tone, phrenoplication 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 plastics with synthetic material (Teflon, polyvinyl alcohol, terylene). In pediatric surgery, stitching of the thoracic barrier is used with parallel rows of corrugating seams, which then tighten, 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 ultrasound examination reveals the absence of diaphragmatic muscles in the fetus. The revealed relaxation should be corrected before complications develop. Injury prevention, diagnosis and adequate treatment of inflammatory processes of the pulmonary parenchyma, pleura, mediastinum, drainage of subdiaphragmatic abscesses help to avoid acquired paralysis of the diaphragm.