Diaphragmatic hernia is a condition when an organ in the abdominal cavity rises and enters the chest cavity, through an abnormal opening in the diaphragm. The hole can be located behind and to the side of the diaphragm (Bochdalek hernia) or in front of the diaphragm (Morgagni hernia). The diaphragm is a dome-shaped muscle that helps with breathing. This muscle is located between the chest and abdominal cavities, and separates the organs of the heart and lungs from the abdominal organs (stomach, intestines, spleen, liver).
Diaphragmatic hernia is a rare disorder. However, if it occurs, medical treatment must be done immediately to prevent risks that can threaten the baby's life.
Causes of Diaphragm Hernia
Based on the cause, diaphragmatic hernia is divided into two types, namely:
- congenital diaphragmatic hernia, occurs when the diaphragm does not fully develop while still in the uterus. This condition causes the organs in the abdomen to move up into the chest cavity and occupy the space where the lungs are supposed to develop. It is not known exactly how this condition can occur. However, there are several factors that are thought to cause disruption of the development of organs in the fetus, namely:
- Genetic and chromosomal abnormalities
- Exposure to chemicals from the surrounding environment
- Mothers who lack nutritional intake during pregnancy.
- Acquired diaphragmatic hernia, is a type of diaphragmatic hernia caused by an injury from a blunt object or a puncture. This condition causes damage to the diaphragm and causes the organs in the abdomen to rise into the chest cavity. Several conditions can cause this type of diaphragmatic hernia, namely:
- Blunt object injury due to accident
- Falling and experiencing a hard impact in the chest or stomach area
- Surgery on the chest and abdomen
- Gunshot or stab wounds.
Symptoms of a Diaphragm Hernia
The main symptom of a diaphragmatic hernia is difficulty breathing. In congenital diaphragmatic hernia, this symptom is caused by underdeveloped lung tissue. While the diaphragmatic hernia is obtained, breathing problems are caused by the diaphragm muscle not functioning properly due to the pressure that occurs. This condition results in reduced levels of inhaled oxygen.
Low intake of inhaled oxygen can trigger other symptoms, namely:
- Fast heart rate
- Quick breath
- Blue skin color.
Diaphragm Hernia Diagnosis
Most cases of congenital diaphragmatic hernia can be diagnosed in the womb. Through ultrasound examination (USG) pregnancy, doctors can detect abnormalities that occur in the lungs and diaphragm of the fetus.
In some cases, a diaphragmatic hernia is not detected during pregnancy and is only seen when the baby is born. Doctors suspect a baby has a congenital diaphragmatic hernia if there are symptoms, which are confirmed by a physical examination. Physical examination is also carried out on patients with acquired diaphragmatic hernia, namely by:
- palpation, namely feeling and pressing the body to check the condition of the stomach. Patients with diaphragmatic hernia have an abdominal condition that does not feel full when pressed because the abdominal organs rise into the chest cavity.
- percussion, namely tapping the surface of the abdomen with the fingers to check the condition of the internal abdominal organs.
- Auscultation, the examination of bowel sounds using a stethoscope to detect whether bowel sounds are heard in the chest area.
To be sure, sometimes further inspection needs to be done. Among others are:
- chest X-ray, to examine and detect abnormalities that may occur in the lungs, diaphragm, and internal organs
- ultrasound, to produce images of the condition of the abdominal and chest cavities.
- CT scan, to examine the condition of the diaphragm and abdominal organs from various angles.
- MRI, to evaluate and examine the organs in the body in more detail.
Blood gas analyzers are also performed to check levels of oxygen, carbon dioxide, and the acidity or pH of the blood.
Diaphragm Hernia Treatment
Diaphragmatic hernias that are identified after the baby is born require surgery. However, there are several factors to consider before the operation is performed, namely:
- Health history and overall health condition of the baby.
- The severity of the diaphragmatic hernia.
- The baby's body's response to certain medications, procedures, or therapies.
Based on these factors, the doctor will determine several stages of treatment, namely:
- Neonatal intensive care. The initial stage of treatment before the baby undergoes surgery. This treatment is carried out in the neonatal intensive care unit (NICU) and aims to increase oxygen intake and stabilize the baby's condition. While in the NICU, the baby will be assisted with a breathing apparatus, namely a mechanical ventilator, to breathe. This action is taken because babies with diaphragmatic hernias are unable to breathe effectively due to their underdeveloped lungs.
- ECMO (extracorporeal membrane oxygenation). Infants with diaphragmatic hernias with very weak conditions will undergo treatment with the help of a heart and lung replacement machine (ECMO). The ECMO machine will help the heart and lungs function in delivering oxygen into the bloodstream and pumping blood to the body. ECMO is used until the baby's condition is stable and improving.
- Operation.After the baby's condition is quite good and stable, surgery will be performed by a pediatric surgeon. The stomach, intestines, and other abdominal organs will be moved from the chest cavity back into the abdominal cavity, then the opening in the diaphragm will be closed. Surgery should be performed 48-72 hours after the baby is born.
Most babies will continue to undergo postoperative care in the NICU. Although the abdominal organs have returned to their position, the lungs are still in the developmental stage. The baby will still be assisted by a respirator for some time after surgery. After that, even though his condition is stable and no longer needs a ventilator, the baby will still need oxygen and medication to help him breathe for several weeks or months. Babies are allowed to go home if they are able to breathe on their own without breathing apparatus and supplemental oxygen, and their weight has increased without nutritional infusions.
For patients with acquired diaphragmatic hernia, surgery needs to be performed after the patient is stable. This action is done to prevent complications due to bleeding from the diaphragm injury experienced.
If the baby is known to have had a diaphragmatic hernia since he was in the womb, the doctor can take steps to treat it through the FETO method (fetal endoluminal tracheal occlusion). FETO is a type of keyhole surgery (laparoscopy) which is performed by inserting a special balloon into the windpipe when the fetus is 26-28 weeks old. This balloon will stimulate the lungs of the fetus to develop. After lung development begins to look normal, the balloon will be removed, either while the fetus is still in the womb or after birth. FETO is useful for preventing respiratory disorders after birth, which occur due to diaphragmatic hernia.
Diaphragm Hernia Prevention
The prevention of diaphragmatic hernia is not yet known. However, routine prenatal care is important to detect any disturbances in the fetus, as well as determine the appropriate treatment steps before, during, and after delivery.
Meanwhile, there are steps you can take to prevent an acquired diaphragmatic hernia. Among others are:
- Be careful when driving a motorized vehicle. Use a seat belt when driving a car and a helmet when riding a motorcycle.
- Avoid activities that risk causing injury to the chest or abdomen.
- Avoid excessive alcohol consumption, because it can increase the risk of accidents, especially when driving.
- Be careful when doing activities that involve sharp objects, such as knives or scissors.
Complications of Diaphragm Hernia
Some of the complications that can occur due to a diaphragmatic hernia include:
- Lung infection.
- Impaired growth and mental development in infants. Babies can have impaired coordination of the body, so it will be difficult or take longer to learn to roll, sit, crawl, stand, and walk. Physiotherapy, speech therapy, and occupational therapy can be done to improve muscle strength and coordination.
