Difference between revisions of "Hiatal Hernia"

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==Introduction==
 
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A hiatal hernia is an abnormality of the diaphragm that allows part of the stomach and the abdominal oesophagus to displace into the thoracic cavity.  Two types of hiatal hernia have been recognised in the dog and cat:
 
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:'''Sliding hiatal hernia''' (type I) - Cranial displacement of the distal oesophagus and stomach into the mediastinum through the oesophageal hiatus of the diaphragm.  This is the most common form and it can occur in the dog and cat as a congenital or acquired lesion. Congenital hernias result from the incomplete fusion of the ''septum transversum'' (which forms the diaphragm) during early embryonic development.
 
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:'''Para-oesophageal''' or '''Rolling hiatal hernia''' (type II) - Cranial displacement of the gastric fundus into mediastinum through the oesophageal hiatus but adjacent to the oesophagus and gastric cardia which remain in their normal positions.  This form of hernia is rare in animals.
 
  
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==Signalment==
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{{dog}}
  
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'''Acquired''' hernias can occur in any breed of dog or cat and these often occur with disorders that cause increases in intra-abdominal pressure (such as chronic vomiting) or decreases in intrathoracic pressure (such as intermittent airway obstruction seen with [[Laryngeal Paralysis|laryngeal paralysis]] and [[Brachycephalic Airway Syndrome|brachycephalic obstructive airway syndrome]] (BOAS)).
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==Typical Signalment==
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Dogs that are predisposed to this disorder include:
  
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Breeds of dog that develop '''congenital''' sliding hernias include Chinese Shar-peis and Chow-chows whereas brachycephalic dogs (such as English and French bulldogs) often develop acquired hernias.
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<gallery>
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Image:Shar_pei.jpg|'''Shar Pei'''<p>WikiCommons
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Image:Chow_chow.jpg|'''Chow Chow'''<p>WikiCommons
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Image:Bulldog.jpg|'''Bulldog'''<p>WikiCommons
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Image:French_bulldog.jpg|'''French Bulldog'''<p>WikiCommons
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</gallery>
  
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==Diagnosis==
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==Description==  
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===Clinical Signs===
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A hiatal hernia is a diaphragmatic abnormality that allows part of the stomach and the abdominal oesophagus to prolapse into the thoracic cavity.
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Some animals may be asymptomatic but otherwise clinical signs include:
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Two types of hiatal hernia have been recognized in the dog and cat:
  
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'''Regurgitation''' due to impaired function of the herniated lower oesophageal sphincter
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*'''Sliding hiatal hernia''' - Cranial displacement of the distal oesophagus and stomach into mediastinum through the oesophageal hiatus.This is the most common form. It can occur in the dog and cat and may occur as a congenital or acquired lesion. Congenital hernias result from incomplete fusion of the diaphragm during early embryonic development.
  
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'''Hypersalivation''' related to regurgitation
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*'''Para-oesophageal hiatal hernia''' - Cranial displacement of part of the stomach into mediastinum through a defect ''adjacent'' to the oesophageal hiatus.
  
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'''Dyspnoea''' and '''coughing''' if the hernia is large and impinges on the lungs or if the animal develops aspiration pneumonia as a result of regurgitation
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Acquired hernias can occur in any breed of dog or cat. The cause is unknown but it is suspected to result from disorders that cause increases in intra-abdominal pressure (ie chronic vomiting) or increases in negative intrathoracic pressure (ie intermittent airway obstruction seen with [[Laryngeal Paralysis - Canine|laryngeal paralysis]]).
  
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'''Dehydration''' and '''weight loss''' due to chronic regurgitation
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==Diagnosis==
  
 +
===Clinical Signs===
 +
Some animals may be asymptomatic but otherwise clinical signs include:
 +
*regurgitation
 +
*vomiting
 +
*hypersalivation
 +
*dyspnoea
 +
*coughing
 +
*dehydration
 +
*weight loss
 
===Diagnostic Imaging===
 
===Diagnostic Imaging===
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'''Plain survey radiographs''' may show a gas-filled soft tissue opacity in the caudodorsal thorax, continuous with the diaphragmatic margin. Secondary [[Megaoesophagus|megaoesophagus]] may develop in longstanding cases and an alveolar lung pattern may be apparent, especially cranio-ventrally, if the animal is developing aspiration pneumonia. '''Barium contrast studies''' may be used to confirm a diagnosis. Intermittent hiatal hernias can be difficult to detect and therefore it is sometimes necessary to put pressure on the abdomen during radiography to induce displacement of the stomach.
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*'''Plain survey radiographs''' may visualise a caudodorsal gas-filled intrathoracic soft tissue opacity which is diagnostic of a hiatal hernia.Oesophageal dilatation and alveolar consolidation may be present with aspiration pneumonia.
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*'''Barium contrast studies''' may be used to confirm a diagnosis.
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'''Fluoroscopy''' can be used to identify cases of intermittent herniation if the condition is still suspected after plain radiography.
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Intermittent hiatal hernias can be difficult to detect and therefore it is sometimes necessary to put pressure on the abdomen during the radiography procedure to induce displacement of the stomach.
  
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'''Endoscopy''' may demonstrate cranial displacement of the lower oesophageal sphincter and a large oesophageal hiatus.
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*'''Fluoroscopy''' can be used to assess for intermittent herniation if a hiatal hernia is suspected by the survey radiographs.
 +
*'''Endoscopy''' may demonstrate cranial displacement of the caudal oesophageal sphincter and a large oesophageal hiatus.
  
 
==Treatment==
 
==Treatment==
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If the hernia is acquired, the underlying cause should be treated.
 
  
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===Medical Management===
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'''Medical therapy''' should be attempted first:
 +
*[[Gastroprotective Drugs]]
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**oral sucralfate
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**gastric acid secretory inhibitors (cimetidine, ranitidine, omeprazole)
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*increase tone of caudal oesophageal sphincter (metoclopramide)
  
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Medical management should be initiated to reduce [[Oesophagitis|oesophagitis]] caused by regurgitation.  Medical management can be continued for cases with acquired hernias and it may achieve success in some cases with congenital hernias.  This approach involves the use of:
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'''Surgical therapy''' is usually attempted with congenital cases :
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:'''[[Gastroprotective Drugs]]''' including oral sucralfate suspensions and gastric acid secretory inhibitors such as cimetidine, ranitidine or omeprazole.
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*laryngeal surgery if [[Laryngeal Paralysis - Canine|laryngeal paralysis]] has contributed to the hernia.
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:A '''low fat diet''' fed from a height will increase the tone of the lower oesophageal sphincter and increase the speed of gastric emptying, reducing the likelihood of regurgitation.
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*diaphragmatic crural apposition, oesophagopexy and gastropexy.
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:'''Metaclopramide''' may also be used to increase the tone of the lower oesophageal sphincter.
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*tube gastropexy with cases with severe oesophagitis or ulceration.
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:'''Antibiotics, nebulisation and coupage''' may be used to manage aspiration pneumonia.
 
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===Surgical Management===
 
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Surgical management can be used with congenital cases (after medical management has been attempted) and to treat the underlying cause in acquired cases.
 
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'''Hernia repair''' is achieved via a cranial ventral coeliotomy.  The oesophageal hiatus is exposed by transection of left triangular ligament (between the liver and diaphragm) and retraction of the liver.  The phreno-oesophageal ligament is partially incised and the oesophagus is retracted into the abdomen until the lower oesopageal sphincter is identified.  Sutures are then placed to reduce the size of the oesophageal hiatus.  An '''oesophagopexy''' may also be performed (tacking the oesophagus to the left body wall) or a '''fundic gastropexy'''. A tube gastropexy has the added advantage of allowing cases to be fed if they are suffering from severe [[Oesophagitis|oesophagitis]] or oesophageal ulceration, and also allowing for decompression of the stomach in the early postoperative period.. 
 
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'''Laryngeal surgery or correction of BOAS''' may be performed if this has contributed to the hernia.
 
  
 
==Prognosis==
 
==Prognosis==
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Prognosis is good after surgical repair or aggressive medical management, but complete relief of clinical signs may not be possible.
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Prognosis is good after surgical repair or aggressive medical management.
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{{Learning
 
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|Vetstream = [https://www.vetstream.com/canis/Content/Disease/dis00644.asp, Hiatal hernia]<br>[https://www.vetstream.com/canis/Content/Illustration/ill00366.asp, Hiatal hernia - barium contrast]<br>[https://www.vetstream.com/canis/Content/Illustration/ill00365.asp, Hiatal hernia - radiograph]
 
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|flashcards = [[Small Animal Soft Tissue Surgery Q&A 14]]
 
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|literature search = [http://www.cabdirect.org/search.html?rowId=1&options1=AND&q1=Hiatal+&occuring1=title&rowId=2&options2=AND&q2=Hernia&occuring2=title&rowId=3&options3=AND&q3=&occuring3=freetext&x=55&y=10&publishedstart=yyyy&publishedend=yyyy&calendarInput=yyyy-mm-dd&la=any&it=any&show=all Hiatal Hernia publications]
 
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}}
 
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==References==
 
==References==
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Fossum, T. W. et. al. (2007) '''Small Animal Surgery''' (Third Edition) ''Mosby Elsevier''
 
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Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) '''BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition)''' ''BSAVA''
 
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Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine (Fourth Edition)''' ''Mosby Elsevier''
 
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{{review}}
 
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{{OpenPages}}
 
  
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[[Category:Oesophagus_-_Pathology]]
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*Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) '''BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition)''' ''BSAVA''
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[[Category:Oesophageal Diseases - Cat]][[Category:Peritoneal Cavity Diseases - Cat]][[Category:Peritoneal Cavity Diseases - Dog]][[Category:Oesophageal Diseases - Dog]]
 
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[[Category:Expert_Review - Small Animal]]
 
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[[Category:Peritoneal_Cavity_-_Developmental_Pathology]]
 
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[[Category:Muscles - Developmental Pathology]]
 
  
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[https://www.vetstream.com/canis/Content/Disease/dis00644.asp]
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*Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine (Fourth Edition)''' ''Mosby Elsevier''

Revision as of 10:12, 25 August 2009

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Category:WikiClinical CanineCow

Typical Signalment

Dogs that are predisposed to this disorder include:

  • Shar Pei

    WikiCommons

  • Chow Chow

    WikiCommons

  • Bulldog

    WikiCommons

  • French Bulldog

    WikiCommons

Description

A hiatal hernia is a diaphragmatic abnormality that allows part of the stomach and the abdominal oesophagus to prolapse into the thoracic cavity. Two types of hiatal hernia have been recognized in the dog and cat:

  • Sliding hiatal hernia - Cranial displacement of the distal oesophagus and stomach into mediastinum through the oesophageal hiatus.This is the most common form. It can occur in the dog and cat and may occur as a congenital or acquired lesion. Congenital hernias result from incomplete fusion of the diaphragm during early embryonic development.
  • Para-oesophageal hiatal hernia - Cranial displacement of part of the stomach into mediastinum through a defect adjacent to the oesophageal hiatus.

Acquired hernias can occur in any breed of dog or cat. The cause is unknown but it is suspected to result from disorders that cause increases in intra-abdominal pressure (ie chronic vomiting) or increases in negative intrathoracic pressure (ie intermittent airway obstruction seen with laryngeal paralysis).

Diagnosis

Clinical Signs

Some animals may be asymptomatic but otherwise clinical signs include:

  • regurgitation
  • vomiting
  • hypersalivation
  • dyspnoea
  • coughing
  • dehydration
  • weight loss

Diagnostic Imaging

  • Plain survey radiographs may visualise a caudodorsal gas-filled intrathoracic soft tissue opacity which is diagnostic of a hiatal hernia.Oesophageal dilatation and alveolar consolidation may be present with aspiration pneumonia.
  • Barium contrast studies may be used to confirm a diagnosis.

Intermittent hiatal hernias can be difficult to detect and therefore it is sometimes necessary to put pressure on the abdomen during the radiography procedure to induce displacement of the stomach.

  • Fluoroscopy can be used to assess for intermittent herniation if a hiatal hernia is suspected by the survey radiographs.
  • Endoscopy may demonstrate cranial displacement of the caudal oesophageal sphincter and a large oesophageal hiatus.

Treatment

Medical therapy should be attempted first:

  • Gastroprotective Drugs
    • oral sucralfate
    • gastric acid secretory inhibitors (cimetidine, ranitidine, omeprazole)
  • increase tone of caudal oesophageal sphincter (metoclopramide)

Surgical therapy is usually attempted with congenital cases :

  • laryngeal surgery if laryngeal paralysis has contributed to the hernia.
  • diaphragmatic crural apposition, oesophagopexy and gastropexy.
  • tube gastropexy with cases with severe oesophagitis or ulceration.

Prognosis

Prognosis is good after surgical repair or aggressive medical management.

References

  • Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition) BSAVA
  • Nelson, R.W. and Couto, C.G. (2009) Small Animal Internal Medicine (Fourth Edition) Mosby Elsevier
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