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Types of Hernias
Diaphragmatic Hiatal Umbilical Inguinal Femoral Perineal
Diaphragmatic Hernia
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
Associated Abnormalities
Sternal defects/Pectus excavatum Cranial midline abdominal wall hernia Umbilical hernia Cardiac defects (VSD) PSS Pulmonary vascular disease
Diagnostic Dilemma
20% traumatic diagnosed @ 4 weeks post
trauma:*omentum plug, rent w/no hernia, failure to dx 48% PPHD < 1y; 36%@ 1-4y May not be until as old as 14y: *omentum plug; formed, but weak diaphragm, often incidental-no symptoms
Clinical Signs
Asymptomatic Gravely Ill
Clinical Signs
Respiratory signs > 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
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.
Most often you will be using an imaging modality to confirm a diagnosis of diaphragmatic hernia Survey radiographs
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
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
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
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
Rule outs
Feline asthma Upper Airway disease Tracheal abnormalities
Diagnostics
Survey thoracic and abdominal radiographs CBC and Chem profile Fecal Urinalysis
Fecal results
Normal
CBC results
Normal
Urinalysis
Normal
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
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
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
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
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
The End
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.