Diaphragmatic hernia - why me?

Dear readers,

In the following I would like to explain some points about the "risk factors" for a diaphragmatic hernia.

Patients rightly ask themselves: Why did I get a diaphragmatic hernia? Was it due to heavy lifting, weight training, or a fall?

To understand this, it's important to know that this critical area of the diaphragm is subject to considerable pressure and tensile forces from various directions. The ability to neutralize these forces and maintain stability at the hiatus is determined by several factors: the angles between the crura, their muscle strength and anatomical attachment to the centrum tendineum, the symmetry and orientation of the hiatus itself, the nerve supply, and therefore the ability to quickly respond to pressure peaks, the 3-dimensional arrangement of the esophagus and stomach as well as the heart and aorta, the shape of the spine and thorax, and blood circulation, just to name a few. Despite—or perhaps because of—the complexity of these interrelated factors that complement each other and compensate for weaknesses, the hiatus is fundamentally extremely stable and efficient.

A change in any of these factors can lead to an imbalance in the system. Scoliosis, for example, leads to asymmetry in the hiatus and is considered a risk factor. Rapid longitudinal growth during puberty affects muscle strength and important angles in the sagittal plane of the crura in the hiatus. Many factors are hereditary and lead to a higher incidence of diaphragmatic hernias within a family. The constantly increased abdominal pressure in obesity also seems to play a certain role. The diaphragm can no longer defend itself against the constantly attacking forces. It begins to give way and slowly "breaks apart" piece by piece.

Some of you will now be thinking, but none of this applies to me! But we have to take into account that we cannot measure most of the factors of diaphragmatic instability and can only find out more during an operation. But it is true: we often do not know the cause.

Can the diaphragm also suddenly rupture due to great stress?

Probably not, but the following should be taken into account: If the diaphragm gives way as described above, compensation mechanisms are activated in the body. This makes it possible to maintain a certain stability of the hiatus. However, if a sudden stress event occurs, the system loses its very last support and symptoms immediately arise. But the actual diaphragmatic hernia had already occurred beforehand. Pregnancy is a classic pressure load. You can read about the effects here in a letter to me:

"My health problems began around 7 years ago after a twin pregnancy, which was probably a great strain on the stomach and diaphragm due to the "space distribution". For the first time, I had the problem that I got laryngitis as a result of a cold, which was difficult to heal and lasted for several weeks. In the years that followed, there were repeated times when I felt healthy - apart from frequent sore throats - but at the same time the laryngitis increased. My ENT doctor suspected even then that reflux could be the cause, so I went for a gastroscopy for the first time in 2009. This, however, showed no findings. Time passed and in 2011, with three consecutive sore throats, I was without a voice(!) for almost half a year, which was a great strain on family, friends and also on my job. After ups and downs, in 2013 I had another very severe laryngitis with hoarseness for 5 months. This time my ENT doctor prescribed me pantoprazole (2x40 mg) and another gastroscopy was performed. This time the diagnosis was a diaphragmatic hernia. The doctor who carried out the examination advised me to continue with medication with acid blockers. There was nothing more that could be done.

I continued to take 40 mg of pantoprazole, and when I had laryngitis I also took 2 x 40 mg. I also paid close attention to the composition of my diet, eating small meals and not eating late. Physically, this was not very good for me, as I was already very slim and was now losing even more weight and strength. The prospect of taking pantoprazole for the rest of my life also worried me - both because of possible long-term effects and because of the lack of absorption of certain nutrients. Time with my children was already overshadowed by my symptoms. Now my children are already at school and I am getting sicker and weaker... Yours, Anne.

Anne described it beautifully in her letter: pregnancy, and particularly twin pregnancies, is actually a significant risk factor for the stability of the diaphragm. The constant pressure in the abdomen increases enormously as the fetus matures. A woman's body can only do this because the pregnancy hormones released make the tissue soft and pliable. This is the only way nature can achieve this feat. A man would not survive a pregnancy. Of course, the hormones also affect the diaphragm. The constantly increasing pressure is countered by an progressively decreasing stability of the diaphragm. The result: the natural small gap in the diaphragm widens, the stomach is practically squeezed into it, the esophagus shifts and heartburn is not uncommon during pregnancy. If this shift was not too far, everything slips back into its old place after the birth and the system functions as normal.

Unfortunately, it was not like that for Anne: two children in one belly was too much. Anne's entire system had actually recovered quite well, but the gases rising from the stomach could no longer be fully controlled. Aerosols from acids and enzymes in the stomach hit the larynx first. The result: recurring laryngitis, pain, loss of voice and hoarseness. But that was not all. The sore mucous membranes formed an ideal implantation site for aggressive bacteria and viruses. This led to further serious inflammations. One thing led to another: the larynx is attacked day and night, the immune system becomes exhausted and the prescribed medication also removes important active ingredients. The body becomes weaker, the daily defensive battle wears down body and soul, side effects develop and life slides more and more into a downward spiral with no hope of recovery.

Simply combating the symptoms endlessly would ultimately not help Anne. We had to eliminate the cause. We decided to operate to finally eliminate the cause. Her symptoms disappeared from one day to the next. Anne's nightmare was suddenly over. She can eat normally again, is as active as before, and the children have their mother back! And now there is so much to catch up on...

Yours

Dr. med. Eckhard Löhde