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FELINE-Peritoneopericardial Diaphramatic Hernia in Cats
FELINE-Peritoneopericardial Diaphramatic Hernia in Cats
Peritoneopericardial
FOCAL POINT
Diaphragmatic Hernia
★ Surgical correction of
peritoneopericardial
in Cats
diaphragmatic hernia is
recommended for all cats
University of Bern
except those that are old and
Bern, Switzerland
asymptomatic; the procedure
often leads to long-term survival.
Reto Neiger, DrMedVet
KEY FACTS
■ Peritoneopericardial hernia is the
most common congenital heart
P eritoneopericardial diaphragmatic hernia is a congenital defect that per-
mits communication between the pericardial and abdominal cavities.
The condition is attributed to an abnormality in embryogenesis of the
ventral portion of the diaphragm. Several theories on the embryogenesis have
been described in detail.1
defect found in cats 2 years of
age and older. In humans, peritoneopericardial diaphragmatic hernia can result from trau-
ma because the diaphragm forms part of the pericardium.2 In cats, however,
■ The hernia is often an incidental trauma can never cause such a hernia because the pericardium is not in direct
finding in routine thoracic contact with the diaphragm.3 Trauma may, however, worsen an existing hernia
radiography. in a cat.
Pleuroperitoneal diaphragmatic hernia is the most common congenital heart
■ The most common clinical signs defect diagnosed in cats 2 years of age and older.4 Berry and coworkers dis-
are nonspecific and relate to the cussed the differential diagnosis of this condition and gave the signalment of
respiratory system (dyspnea) and 10 affected cats.5 Wallace and coworkers explained the best surgical technique
the gastrointestinal system for correcting the condition in cats and gave some information on another 10
(vomiting or diarrhea). cats.6
Pleuroperitoneal diaphragmatic hernia is often an incidental finding from a
■ The liver is the organ that routine thoracic radiograph. The most common clinical signs are respiratory
herniates most often into the (e.g., dyspnea). Gastrointestinal signs (e.g., vomiting or diarrhea) are also com-
pericardium, followed by the mon. This article reviews published clinical and pathologic data on cats with
gallbladder and small intestine. pleuroperitoneal diaphragmatic hernia and reports two more cases.
CASE REPORTS
Case 1
Diagnosis
A 10-year-old castrated male Persian cat was presented with a 2-week history
of intermittent fever, anorexia, and lethargy. On physical examination, the cat
was quiet but alert, weighed 5.2 kilograms, and had a rectal temperature of
40.6˚C. There was moderate tachypnea (68 breaths/min) and normal lung
sounds. Heart auscultation was unremarkable, and femoral pulses of 212 beats
Small Animal The Compendium May 1996
Treatment
After premedication with di-
azepam (0.2 mg/kg intravenous-
ly), anesthesia was induced with
ketamine hydrochloride (3 mg/kg
intravenously). The cat was intu-
bated with a cuffed endotracheal
tube to enable the anesthetist to
Figure 2—Ultrasonography of thoracic mass from case 1. The transducer was held control ventilation and to permit
medially and directly caudal to the sternum. The mass is 1.6 centimeters in diameter positive-pressure ventilation.
and has sharp margins. The echogenicity is not completely homogenous. The normal
contour of the diaphragm is interrupted.
Anesthesia was maintained with
halothane in oxygen.
RADIOGRAPHY ■ ULTRASONOGRAPHY
The Compendium May 1996 Small Animal
Exploratory laparotomy revealed a herniated liver the liver, structures that resembled intestines were adja-
lobe (1.5 cm in diameter) beyond a pericardioperi- cent to the diaphragm.
toneal communication (Figure 3). The liver lobe was Ultrasonography showed that parts of the liver pro-
not strangulated but had adhesions to the tendinous truded through the diaphragm into the pericardium. It
part of the diaphragm. After the liver lobe was reposi- also showed pericardial effusion. The diagnosis was peri-
tioned and biopsy samples were collected from the toneopericardial diaphragmatic hernia.
lobe, the diaphragm was closed in a single layer with 2-
0 polydioxanone in a continuous suture pattern. Biopsy Treatment
samples were collected from the abdominal mass, Anesthesia was induced with thiobarbiturate (12
which seemed to be a lymph node. mg/kg intravenously) after premedication with di-
azepam (0.2 mg/kg intravenously). After endotracheal
Results intubation with a cuffed tube, anesthesia was main-
The cat recovered un- tained with halothane in
eventfully. The findings oxygen. Surgical exploration
from the biopsy of the ab- via a cranial midline abdom-
dominal mass were consis- inal incision revealed two
tent with a reactive lymph liver lobes within the peri-
node. The liver biopsy re- cardium. The herniated liver
sults were considered nor- had adhesions with the
mal. According to the own- tendinous part of the di-
er, the cat was doing well 1 aphragm. The rest of the liv-
year after the operation. er had no adhesions. The
liver lobes were replaced into
Case 2 the abdominal cavity, and
Diagnosis the defect was repaired as
A 5-month-old male Per- Figure 3—View through the ventral part of the diaphragm described in case 1. The cat
sian cat was presented with into the pericardial sac. The herniated liver lobe has al- died 3 years later after being
ready been repositioned.
a history of weight loss, hit by a car.
vomiting, and dyspnea. The
cat was thin, mildly lethar-
gic, and had moderate con-
junctivitis. Respiration rate
was 80 breaths per minute,
and lung sounds were nor-
mal. All other vital signs
were within normal limits.
Hematologic abnormali-
ties included leukocytosis
(19,300 cells/µl) with mild
eosinophilia (1,810 cells/µl)
and lymphocytosis (8,600
cells/µl). A test for feline
leukemia virus was negative.
The serum chemistry pro-
file was within normal lim-
its for a cat of that age.
Thoracic radiographs
demonstrated a large car-
diac silhouette (Figure 4)
with the trachea displaced Figure 4—Lateral thoracic radiograph from case 2. The cardiac shadow is severely increased
dorsally. The ventral part of and fills approximately two thirds of the thoracic cavity. The trachea is elevated and lies ad-
jacent to the vertebral column. The contour of the diaphragm cannot be visualized in the
the diaphragm was not
ventral part, and gastrointestinal structures instead of liver lie caudal to the diaphragm.
clearly visible. In place of
TABLE I
Signalment and Clinical Findings for Cats with Peritoneopericardial Diaphragmatic Hernia
Breed Sex Age Clinical Physical Diagnostic Herniated Other Reference
Signs Findings Procedures Structures Problems
Domestic Male 8 months Sneezing Pyrexia, muffled Thoracic Left and right — 11
shorthair heart sounds, radiography,a middle liver lobes
increased lung necropsy
sounds
Siamese Female 5 months Abdominal Ascites, muffled Necropsya Right liver lobe — 12
cross enlargement heart sounds
Domestic Castrated 8 years Anorexia, Tachypnea, Thoracic Three liver lobes, Myelolipoma 14
shorthair male dyspnea muffled heart radiography,a gallbladder of the liver
sounds surgery
Domestic Female 8 years Weight loss, Cachexia, Thoracic Parts of liver, Polycystic kidneys, 17
shorthair anorexia muffled heart radiography, gallbladder anemia
sounds, large fluoroscopy of the
kidneys thorax, surgery,a
necropsy
Siamese Male 2 years Weight loss, Cachexia Thoracic Parts of small Incomplete 18
vomiting radiography,a surgery intestines, one sternum
liver lobe
Small Animal The Compendium May 1996
TABLE I (continued)
Signalment and Clinical Findings for Cats with Peritoneopericardial Diaphragmatic Hernia
Breed Sex Age Clinical Physical Diagnostic Herniated Other Reference
Signs Findings Procedures Structures Problems
Persian Castrated 2 years Vomiting, Normal Thoracic Two liver lobes Intussusception, 20
male anorexia radiography, trichobezoar
gastrointestinal
study,a surgery
Domestic Castrated 8 months Lethargy, weight Pyrexia, Thoracic One liver lobe Thrombocytopenia, 21
shorthair male loss, anorexia tachypnea, radiography, proteinuria
diarrhea tachycardia, gastrointestinal
cachexia study, angiography,a
surgery
Domestic — 2.5 years Dyspnea Crepitation over Thoracic Several liver lobes Increased liver 22
longhair last ribs radiography, enzymes
gastrointestinal
study, surgerya
TABLE I (continued)
Signalment and Clinical Findings for Cats with Peritoneopericardial Diaphragmatic Hernia
Clinical Physical Diagnostic Herniated Other
Breed Sex Age Signs Findings Procedures Structures Problems Reference
Persian Castrated 7 years Cyanosis Muffled heart Thoracic Liver, falciform Sternal deformity 28
male sounds, cranial radiography, fat
apex beat ultrasonographya
Domestic Castrated 4.5 years Lethargy, Increased lung Thoracic Right middle liver Myelolipoma of 29
longhair male anorexia, sounds, cranial radiography, lobe, part of the liver
vomiting apex beat electrocardiography, gallbladder
angiography,
ultrasonography,
surgerya
Persian Female 8 months Anorexia, Pyrexia, tachypnea, Thoracic Several liver Thrombocytopenia, 31
lethargy, muffled heart radiography, lobes, gallbladder anemia,
dyspnea sounds, increased peritoneography,a lymphopenia
lung sounds ultrasonography,
necropsy
Domestic Male 2 years Dyspnea Tachypnea, Thoracic Right middle liver Portosystemic 32
shorthair muffled heart radiography, lobe shunt
sounds, heart electrocardiography,
murmur ultrasonography,a
surgery
a
This procedure confirmed the diagnosis of peritoneopericardial diaphragmatic hernia in this case.
Other Cases cases. Table III shows the frequency of various clinical
Diagnosis signs and physical abnormalities in cats with diagnosed
Table I summarizes the reports of 32 other feline cases peritoneopericardial diaphragmatic hernia.
of peritoneopericardial diaphragmatic hernia published The hernia was diagnosed during necropsy in nine
in 28 publications.1,3,7–32 It includes signalment data for cases. Thoracic radiography was diagnostic for nine
most of the cases.5,6 The cats’ ages ranged from 6 days to cats. Further diagnostic procedures (e.g., upper gas-
14 years (mean 3.7 years). In six reports, the breed was trointestinal study in three cases, angiography in three
not mentioned. Table II summarizes breed data from re- cases, ultrasonography in two cases, and positive-con-
ported cases, including the cases described in Table I trast peritoneography in one case) were necessary for
plus 20 more cases.5,6 Thirty of 52 affected cats were re- others. Echocardiography was done to confirm the her-
ported to be female, 18 were reported to be male. The nia in all 10 of the cats described by Wallace and
sex was not mentioned in the descriptions of the other coworkers.6
Clinical Signs
Physical Abnormality
Clinical signs of peritoneopericardial di-
Muffled heart sounds 15 aphragmatic hernia in cats can be nonspecific
Tachypnea 7 (e.g., anorexia, weight loss, or lethargy). Howev-
Pyrexia 3 er, respiratory signs (e.g., dyspnea) are the most
Increased lung sounds 3 common manifestations. Gastrointestinal signs
Heart murmur 2 (e.g., vomiting or diarrhea) are also common.
Cranial displacement of the apex beat 2 Signs of cardiac compromise (e.g., abdominal
Pneumonia 2 swelling12) are uncommon but were implicated
Ascites 1 in an acute death.13,19 On the other hand, the
Tachycardia 1 hernia is often an incidental finding in the ex-
Arrhythmia 1 amination of asymptomatic cats.6,26 Other cases
remain undiagnosed for years and are discovered
at necropsy.3
The physical examination findings are often
membrane in this area might result in a peritoneoperi- unremarkable. Muffled heart sounds or a displaced
cardial communication.41,42 apex beat can arouse suspicion.29 If concurrent cardial
Because the transverse septum develops unpaired, the malformations are present, a heart murmur may be de-
latest hypothesis is that the defect results from traumat- tected.6,26,32 Theoretically, the abdomen might seem
ic rupture5 or toxin exposure in embryonic life as the empty during palpation if the hernia is large and most
liver bud undergoes rapid expansion.32 Diaphragmatic of the abdominal organs are displaced cranially; but
hernia can be produced in rats by deprivation of dietary this finding in a cat has never been reported.44
vitamin A.43 The various congenital diaphragmatic ab-
normalities in humans each have a separate proposed Associated Anomalies
embryogenesis34; the same might be true for cats. Peritoneopericardial diaphragmatic hernia may be
associated with other congenital abnormalities. Ster-
Heritability nal anomalies were the most commonly associated
Peritoneopericardial diaphragmatic hernia has been anomaly, followed by ventral hernia. Polycystic kid-
found in more than one dog from the same litter. neys occurred in one case17 and prognathism in anoth-
Weimaraners are suggested to be predisposed. Never- er.6 One cat had a congenital portosystemic shunt.32 A
Electrocardiography
The electrocardiogram may be normal29 or
arrhythmic32 or may show an axis deviation
because of cardiac displacement.23 Low-volt-
age electrocardiographic readings caused by
the dampening effect of effusion or herniat-
ed abdominal organs have not been reported
to occur in cats.50
Figure 7—(A) Lateral view of a human embryo (approximately day 33). (B) The area within the rectangle in A is enlarged to
show the primitive body cavities as viewed from the left side after removal of the lateral body wall. (C) Transverse section
through the embryo at the level shown in B. (From Moore KL [ed]: The Developing Human. Philadelphia, WB Saunders
Co, 1993, p 164. Reproduced with permission).
Detecting Adhesions
In cats with peritoneopericardial di-
aphragmatic hernia, the herniated organs
may have adhesions with structures in the
thorax. Because of the difficulty in assessing
these adhesions noninvasively, surgical cor-
rection may be inadvisable for an old cat
that has no clinical signs related to the her-
nia.44 Noninvasive methods that can clearly
distinguish adhesions (i.e., computed to-
mography and magnetic resonance imaging)
are not readily available in veterinary prac-
tice. Pneumoperitoneography and positive-
contrast peritoneography are of limited val-
ue when herniated viscera seal the defect.
Intrapericardiac adhesions are difficult to see
ultrasonographically.
Figure 8—The four parts of the diaphragm: transverse septum, pleuroperi- Diagnostic Differentials
toneal membrane, dorsal mesentery of the esophagus, and body wall. Even when the clinical and radiographic
(From Wallace J, Mullen HS, Lesser MB: A technique for surgical correc-
signs are strongly suggestive of perito-
tion of peritoneal pericardial diaphragmatic hernia in dogs and cats.
JAAHA 28(6):503–510, 1992. Reproduced with permission.) neopericardial diaphragmatic hernia, the
diagnosis should be confirmed before
surgery. Such diagnostic differentials as
and easily performed, is diagnostic only when bowel pericardial effusion, pericarditis, cardiomyopathy, fi-
loops are present in the pericardium,1 a finding less com- broelastosis, and tricuspid valve dysplasia do not re-
mon in cats than in dogs.44 Computed tomography, if quire surgery.49 Pericardial, mediastinal, pulmonary,
available, would be the best diagnostic procedure, as has pleural, and diaphragmatic masses necessitate thoraco-
been shown in human cases of peritoneopericardial di- tomy.30 Only peritoneopericardial diaphragmatic her-
aphragmatic hernia.38 nia must be corrected via laparotomy. Surgical correc-
Your comprehensive
tion of peritoneopericardial diaphragmatic hernia led
guide to diagnostic to long-term survival in 22 of 25 cats.
Complications
Three cats with peritoneopericardial diaphragmatic
hernia had a myelolipo-
matous change of the
herniated liver, 14,24,29
possibly because of Radiographic Signs of
Peritoneopericardial
New chronic hepatic hypoxia
caused by entrapment Diaphragmatic Hernia
of the affected lobes
within the pericardium. ■ Slightly to greatly
Portal hypertension can enlarged cardiac
also result from an in- silhouette with dorsal
$
149 carcerated liver lobe.12
Anesthesia
displacement of the
trachea49
Robert E. Cartee, Editor ■ Nonuniform radiopacity
Cats undergoing sur-
400 pages, hard cover gery for peritoneoperi- of the cardiac
1597 illustrations cardial diaphragmatic silhouette49
hernia should be intu- ■ Overlapping of the
■ Sonographic diagnosis in dogs and cats, bated to permit posi- cardiac apex and the
including ultrasound, M-mode, pulsed tive-pressure ventilation cupula of the
if the pleural space is
and color Doppler echography diaphragm49
opened. Furthermore,
controlled ventilation ■ Loculated gas or fecal
■ Echocardiography, abdominal and pelvic
allows the anesthetist to densities within the
sonography, and fetal ultrasonography
coordinate respiratory cardiac silhouette49
■ Case illustrations using conventional movements with reduc- ■ A thoracic mass
radiography, computed microfocal tion and suturing of the between the heart
hernia. Routine anes-
tomography, specimen photography, shadow and the
thetic protocols can be
and line drawings used for premedication diaphragm30
and induction. Anes- ■ Microhepatica26
■ Recognition of the disease process and
thesia can be main- ■ Cranial displacement of
courses of treatment tained with halothane gastrointestinal
or isoflurane in oxygen. viscera17,32
■ Sternal deformities1,18
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■ Peritoneopericardial
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PORTAL HYPERTENSION
The Compendium May 1996 Small Animal
26. Harpster NK, Zook BC: The cardiovascular system, in aphragmatic hernia. Am J Surg 139:436–440, 1980.
Holzworth J (ed): Diseases of the Cat: Medicine and Surgery. 39. Butler N, Claireaux AE: Congenital diaphragmatic hernia as
Philadelphia, WB Saunders Co, 1987, pp 911–913. a cause of perinatal mortality. Lancet 1:659–663, 1962.
27. Bailey MQ: What is your diagnosis? JAVMA 192:1753– 40. Baker GJ, Williams CSF: Diaphragmatic pericardial hernia
1754, 1988. in the dog. Vet Rec 78:578–583, 1966.
28. Miller MW, Biller SB: What is your diagnosis? JAVMA 41. Clinton JM: A case of congenital pericardio-peritoneal com-
193:971–972, 1988. munication in a dog. J Am Vet Radiol Soc 8:57–60, 1967.
29. Hey WH, Woodsfield JA, Moon MA: Clinical, echocardio- 42. Bolton GR, Ettinger S, Rousch JC: Congenital perito-
graphic, and radiographic findings of peritoneopericardial neopericardial diaphragmatic hernia in a dog. JAVMA
diaphragmatic hernia in two dogs and a cat. JAVMA 155:723–730, 1969.
195:1245–1248, 1989. 43. Finn JP, Martin CL: Diaphragmatic pericardial hernia. J
30. Lamb CR, Mason GD, Wallace MK: Ultrasonographic diag- Small Anim Pract 10:295–300, 1969.
44. Miller MW, Sisson DD: Pericardial disorders, in Ettinger SJ,
nosis of peritoneopericardial diaphragmatic hernia in a Per-
Feldman EC (eds): Textbook of Veterinary Internal Medicine.
sian cat. Vet Rec 125:186, 1989. Philadelphia, WB Saunders Co, 1995, pp 1032–1045.
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matica (HPPD) bei einer Perserkatze—ein kongenitaler De- cats. Feline Pract:18–43, 1976.
fekt. Tierärztl Prax 19:664–667, 1991. 46. Bellah JR, Spencer CP, Brown DJ, Whitton DL: Congenital
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nia and portacaval shunt in a cat. JAAHA 28:163–166, 1992. pericardial and intracardiac defects in cocker spaniel litter-
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cardial diaphragmatic hernia. Am J Roentgenol Radiat Ther 47. Johnson KA: Diaphragmatic, pericardial, and hiatal hernia,
Nucl Med 57:42–49, 1947. in Slatter D (ed): Textbook of Small Animal Surgery. Philadel-
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