Correct!
5. All of the above
A diaphragmatic hernia can be congenital or acquired and can be through diaphragmatic foramina – those of Morgagni and Bochdaelek or along the esophageal hiatus (Figure 5).
Figure 5. Schematic of the diaphragm showing the locations of diaphragmatic hernias.
Hernias via the foramen of Morgagni are smaller and usually present later in life at the sternocostal angles, whereas the Bochdalek variety are larger and tend to occur posterolaterally.
A hiatal hernia is also a herniation of bowel contents through the diaphragm but are obviously more central and via the esophageal hiatus of the diaphragm. Two types are noted, sliding and paraoesophageal. Hiatal hernias are not usually described as diaphragmatic hernias, but semantically they would seem to fit the definition – a hernia being classically defined as an abnormal protrusion of bowel contents from one body cavity into another.
The literature notes that complications of the paraoesophageal hiatal hernias include strangulation or incarceration as is the case with all hernias. They tend to enlarge with time, age and acquired obesity and surgeons may choose to close them with mesh procedures either laparoscopically or by laparotomy.
It is not inconceivable (but not in the usage of this word from the famous film, The Princess Bride), that the external collapse of the left lung helped protect that side from an aspiration. In most cases aspiration is on the right side due to angulation of the left main stem compared to the right.
Non-invasive ventilation can often push air into the stomach which can usually be of little concern. In this case it created significant problems. Placing a chest tube by any methodology would be a problem as that will likely enter his bowel and perforate it which creates obvious problems and would have made the situation far more fraught for the residents and fellows treating this patient and earned the ire of the surgical or ICU attendings involved in the case.
The Chiladitis sign/syndrome should not be confused with this discussion which is usually a right-sided phenomenon wherein bowel is interposed between liver and diaphragm but can also be seen on the left between spleen and diaphragm.
As far as the author can tell, there are no clear cases of a similar case reported wherein use of non-invasive ventilation caused an acute enlargement of a paraesophageal hernia leading to tension physiology, midline shift, respiratory distress, etc.
The exact terminology to describe is open to discussion – tension hiatal hernia seems reasonable but the term status aerophagia iatrogenicus is more melliflous, leaving aside the correct Latin conjugations. The term status is used in medicine to implying ongoing uncontrolled issues, as in status asthmaticus or status epilepticus. Aerophagia is self-explanatory, iatrogenicus is perhaps the correct Latin conjugation (iatrogenica, vs iatrogenicum etc.?) to imply that this was caused by a well-intentioned medical intervention. Any reader well versed in Latin grammar is invited to correct this or use the last reference to provide input.
The patient is discussing pros/cons of surgical repair with the surgical team since there is a concern for complications such as strangulation or incarceration with ischemia.
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