Vol.18, No.
5 May 1996
Continuing Education Article
FOCAL POINT
★ Surgical correction of
peritoneopericardial
diaphragmatic hernia is
recommended for all cats
except those that are old and
asymptomatic; the procedure
often leads to long-term survival.
KEY FACTS
■ Peritoneopericardial hernia is the
most common congenital heart
defect found in cats 2 years of
age and older.
■ The hernia is often an incidental
finding in routine thoracic
radiography.
■ The most common clinical signs
are nonspecific and relate to the
respiratory system (dyspnea) and
the gastrointestinal system
(vomiting or diarrhea).
■ The liver is the organ that
herniates most often into the
pericardium, followed by the
gallbladder and small intestine.
Spring Feline Focus
Peritoneopericardial
Diaphragmatic Hernia
in Cats
University of Bern
Bern, Switzerland
Reto Neiger, DrMedVet
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
In humans, peritoneopericardial diaphragmatic hernia can result from trau-
ma because the diaphragm forms part of the pericardium.2 In cats, however,
trauma can never cause such a hernia because the pericardium is not in direct
contact with the diaphragm.3 Trauma may, however, worsen an existing hernia
in a cat.
Pleuroperitoneal diaphragmatic hernia is the most common congenital heart
defect diagnosed in cats 2 years of age and older.4 Berry and coworkers dis-
cussed the differential diagnosis of this condition and gave the signalment of
10 affected cats.5 Wallace and coworkers explained the best surgical technique
for correcting the condition in cats and gave some information on another 10
cats.6
Pleuroperitoneal diaphragmatic hernia is often an incidental finding from a
routine thoracic radiograph. The most common clinical signs are respiratory
(e.g., dyspnea). Gastrointestinal signs (e.g., vomiting or diarrhea) are also com-
mon. This article reviews published clinical and pathologic data on cats with
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

per minute were easily palpable.

No other physical abnormalities
were detected.
Complete blood count, bio-
chemistry panel, and urinalysis
were performed. The only abnor-
mality was hyperglobulinemia
(54.7 g/L; reference range, 31 to
35 g/L). Tests for feline leukemia
virus and feline immunodeficien-
cy virus were negative.
Thoracic radiographs (Figure 1)
showed a soft-tissue mass (1.5 cm
in diameter) in the caudoventral
portion of the thorax overlying
the cupula of the diaphragm. The
heart was normal in size and
shape.
Ultrasonography of the thorax
showed that this mass was in direct
contact with the diaphragm and
the pericardium. Its echogenicity
resembled that of the liver (Figure
2). No abnormalities within the
pericardium were noted.
Figure 1—Thoracic radiograph from case 1. A mass in the caudoventral portion of the
thorax (about 1.5 cm in diameter) is in direct contact with the diaphragm. Ultrasonography of the ab-
domen showed another irregular
mass (1 cm in diameter) caudal to
the stomach and near the portal
vein. All other organs were nor-
mal in size, shape, position, and
echogenicity. A fine-needle aspi-
rate of the abdominal mass re-
vealed a mixed population of lym-
phocytes and lymphoblasts with
few neutrophils and macrophages.
This finding, together with the
hyperglobulinemia, probably re-
flected a nonspecific inflammato-
ry process.

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

CARDIAC SILHOUETTE ■ ADHESIONS OF HERNIATED LIVER

Small Animal The Compendium May 1996

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

— Male 1 year Neurologic signs — Necropsya Small and large — 7

intestine, left liver
lobe, gallbladder

— — 6 months Exercise — Necropsya Several liver — 8

intolerance lobes, gallbladder

— — — — — Necropsya Parts of the liver, — 9

gallbladder,
omentum

Domestic Female Adult None — Necropsya Three liver lobes, — 3

shorthair gallbladder,
omentum

Persian Female 4 months Dyspnea Tachypnea, Thoracic Omentum, small — 10

muffled heart radiographya, surgery intestines
sounds

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 Female 6 days None — Necropsya Four liver lobes — 13

shorthair

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

Himalayan — 4 months Dyspnea, — Necropsya Left medial liver Feline infectious 15

anorexia, ascites lobe peritonitis

Domestic Spayed 7 years Polyuria, Tachypnea, weak Thoracic Small intestine, 16

shorthair female polydipsia, pulse, muffled radiography,a left liver lobe,
vomiting heart sounds gastrointestinal omentum
study, 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

Domestic Female 10 years Vaginal — Gastrointestinal Pylorus, spleen, Tooth abscess 1

shorthair discharge studya right liver lobe,
gallbladder

Persian Female 10 years Vomiting — Gastrointestinal Small intestine, 1

studya part of liver

Domestic Female 2 months Dyspnea — Thoracic — 1

shorthair radiographya

Persian Spayed 8 years Seizures — Thoracic — Fused first and 1

female radiographya second sternebrae

— Female 5 months Dyspnea — Necropsya Liver, gallbladder 19

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

Persian Male 8 weeks Dyspnea, Increased lung Thoracic Small intestine, — 23

exercise sounds radiography, large part of liver
intolerance gastrointestinal
study, electrocardiography,
angiography,a necropsy

Domestic Spayed 14 years Dyspnea — Thoracic Several liver Myelolipoma of 24

shorthair female radiography, lobes, part of liver
necropsya omentum, gallbladder

— Female 4 months Seizures, Muffled heart Thoracic Several liver — 25

dyspnea, exercise sounds radiographya lobes, small
intolerance intestine

Persian Female 5 years None Heart murmur Thoracic All right — 26

radiography, surgerya liver lobes
The Compendium May 1996 Small Animal

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

Himalayan Spayed 9 years — — Ultrasonographya — — 26

female

— Spayed 4 years Exercise Muffled heart Thoracic Liver, — 27

female intolerance sounds radiography, falciform fat
angiographya

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 Male 7 months Vomiting, Normal Thoracic Left middle liver — 30

diarrhea radiography, lobe
ultrasonography,a
surgery

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
Diagnosis
Table I summarizes the reports of 32 other feline cases
of peritoneopericardial diaphragmatic hernia published
in 28 publications.1,3,7–32 It includes signalment data for
most of the cases.5,6 The cats’ ages ranged from 6 days to
14 years (mean 3.7 years). In six reports, the breed was
not mentioned. Table II summarizes breed data from re-
ported cases, including the cases described in Table I
plus 20 more cases.5,6 Thirty of 52 affected cats were re-
ported to be female, 18 were reported to be male. The
sex was not mentioned in the descriptions of the other
cases. Table III shows the frequency of various clinical
signs and physical abnormalities in cats with diagnosed
peritoneopericardial diaphragmatic hernia.
The hernia was diagnosed during necropsy in nine
cases. Thoracic radiography was diagnostic for nine
cats. Further diagnostic procedures (e.g., upper gas-
trointestinal study in three cases, angiography in three
cases, ultrasonography in two cases, and positive-con-
trast peritoneography in one case) were necessary for
others. Echocardiography was done to confirm the her-
nia in all 10 of the cats described by Wallace and
coworkers.6

DIAGNOSTIC PROCEDURES ■ RESULTS OF SURGERY

Small Animal The Compendium May 1996

Exploratory laparotomy, the TABLE II The lung buds then grow

most invasive procedure, was Breed Data from Reported Feline Cases of into the pericardioperitoneal
necessary to confirm the diag- Peritoneopericardial Diaphragmatic Hernia canal, thus forming the pleu-
nosis for five cats. Table I dis- ral cavity. As the lungs grow,
Breed Number of Cats
cusses which structures were a pleuropericardial mem-
herniated in 32 affected cats. brane forms cranially and
Domestic shorthair 17
Concurrent congenital defects Persian 12 eventually separates the peri-
were sternal anomaly (7 cas- Domestic longhair 7 cardial cavity from the pleu-
es), ventral hernia (2 cases), Himalayan 4 ral cavities (Figure 6). At the
prognathism (1 case), polycys- Himalayan crossbreed 1 same time, a pleuroperitoneal
tic kidneys (1 case), and por- Siamese 1 membrane forms caudally
tosystemic shunt (1 case). Siamese crossbreed 1 and gradually separates the
Angora 1 pleural cavities from the peri-
Treatment Maine coon 1 toneal cavity34 (Figure 7).
Thoracotomy was per- Russian blue 1 The diaphragm develops
formed on two of the cats Not specified 6 from four structures: the
described in Table I, and la- transverse septum, which will
Total 52
parotomy was performed on form the central tendon; the
14 of these cats as well as on pleuroperitoneal membrane;
all 10 cats discussed by Wallace and coworkers.6 Of the dorsal mesentery of the esophagus, which will form
these animals, 22 survived, 2 died shortly after surgery, the crura of the diaphragm; and parts of the body wall36
and 1 was euthanatized during surgery because of con- (Figure 8).
comitant polycystic kidneys. One cat died 9 months
later, possibly as a result of the hernia because reduction Congenital Hernias
could not be performed owing to severe adhesions. Several congenital diaphragmatic hernias have been
recognized in humans. Hiatal hernias and posterolateral
DISCUSSION defects (through the hiatus pleuroperitonealis [foramen
Although peritoneopericardial diaphragmatic hernia of Bochdalek]) account for 85% of these anomalies in
is probably the most common congenital diaphragmat- humans.2 True defects of the diaphragm and the peri-
ic defect in cats, there is no report of a large series of cardium are very rare.33,37 Only 28 cases have been re-
cats with this anomaly. Berry and coworkers gave the ported: 10 attributed to a congenital defect and 18 sec-
signalment of 10 cats with this hernia but no further ondary to trauma.38 In humans, the diaphragm forms
details.5 Wallace and coworkers described the surgical part of the pericardium, so there is a chance of a trau-
technique used to correct the hernia in 10 cats and the matic peritoneopericardial diaphragmatic hernia. In
postsurgical evaluation.6 cats, however, the pericardial cavity is not in contact
The first reported case of a peritoneopericardial di- with the diaphragm. Traumatic injury to this part of
aphragmatic hernia in a dog was described in 1811 by the diaphragm would result in a pleuroperitoneal her-
J.-B. Gohier.8 The first human case was reported in nia.3 A traumatic event, however, may cause abdominal
190333 and the first feline case in 1909.7 contents to slide through an existing peritoneopericar-
dial diaphragmatic hernia into the pericardial cavity
Embryonic Development and initiate acute clinical signs.22
Embryonic development of the body cavities is com-
plex and only partially understood. By the fourth week Pathogenesis
of development, a pericardial cavity can already be Several theories on the embryonic development of
identified in a human embryo. The embryo has a wall peritoneopericardial diaphragmatic hernia have been
lined with mesothelium that will become the peri- suggested. The lateral pleuroperitoneal membranes and
toneum.34 With the formation of the head fold, the the ventromedial pars sternalis might fail to unite dur-
heart and pericardial cavity are carried ventrally and ing the embryonic development of the abdominal and
caudally.35 The pericardial cavity then opens dorsally thoracic cavities.39 The hernia might result from prena-
into the pericardioperitoneal canals. Each pericar- tal injury to the transverse septum or to the site where
dioperitoneal canal lies lateral to the foregut (the future the transverse septum fuses with the pleuroperitoneal
esophagus) and dorsal to the transverse septum (the fu- membranes.40 Faulty development of the dorsolateral
ture diaphragm)34 (Figure 5). part of the transverse septum or rupture of a thin tissue

PERICARDIAL CAVITY ■ TRANSVERSE SEPTUM ■ TRAUMA

Small Animal The Compendium May 1996

theless, no conclusive evidence exists that this le-

TABLE III sion is hereditary.44 In cats, congenital diaphrag-
Clinical Signs and Physical Abnormalities in Reported
matic hernias have been attributed to an autoso-
Feline Cases of Peritoneopericardial Diaphragmatic Hernia
mal recessive gene; the incidence of the condition
Clinical Sign or Abnormality Number of Cats Affected is between 1:500 and 1:1500 births.45

Clinical Sign Signalment of Affected Cats

Dyspnea 11 Forty-two percent of feline cases of perito-
Vomiting 7 neopericardial diaphragmatic hernia are reported-
Anorexia 7
ly diagnosed before the cat is 1 year of age, but
the condition has been discovered in animals as
Exercise intolerance 5
old as 14 years. The mean age of cats at diagnosis
Lethargy 4 is 3.7 years.
Weight loss 2 Among humans with peritoneopericardial di-
Diarrhea 2 aphragmatic hernia, males predominate 6:1. 38
Abdominal enlargement 2 Among feline cases in which the sex of the cat is
Seizures 2 known, however, 30 of the cats were female and
Sneezing 1 18 were male. Out of 52 feline case reports in
Polyuria and polydipsia 1 which breed was mentioned, 12 were Persians. In-
Vaginal discharge 1 cluding my two patients, Persians account for
Cyanosis 1 26% of the reported cases, thus possibly reflecting
No clinical signs 5 a breed predisposition.

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

PERSIAN CATS ■ STERNAL ANOMALIES ■ CONGENITAL ABNORMALITIES

Small Animal The Compendium May 1996

similar anomaly (a portoazygos shunt) oc-

curred in a 5-month-old beagle with peri-
toneopericardial diaphragmatic hernia.6
A littermate of a shorthair tabby kitten
with peritoneopericardial diaphragmatic
hernia had hydrocephalus.13 This finding is
interesting because deaths of human
neonates with congenital diaphragmatic
hernia are commonly associated with
anomalies of the central nervous system,
including hydrocephalus.43 Although con-
genital heart defects have occurred in dogs
with peritoneopericardial diaphragmatic
hernia, none of the reported cats had such
defects.46
Most of the congenital abnormalities asso-
ciated with peritoneopericardial diaphrag-
matic hernia are not inherited but due to ac-
Figure 5—Schematic of a human embryo (approximately day 24). (A) The cidents of embryogenesis. 47 Associated
lateral wall of the pericardial cavity has been removed to show the primitive abnormalities, however, occurred in only 1
heart. (B) Transverse section showing the relationship of the pericardioperi- of 28 human patients.48
toneal canals to the transverse septum and the foregut. (C) Lateral view with
the heart removed. (D) The pericardioperitoneal canals arise from the dorsal
Diagnosis
wall of the pericardial cavity and pass on each side of the foregut to join the
peritoneal cavity. (From Moore KL [ed]: The Developing Human. Philadel- Thoracic Radiography
phia, WB Saunders Co, 1988, pp 159–169. Reproduced with permission.) A routine thoracic radiograph may suggest
or even confirm the diagnosis of perito-
neopericardial diaphragmatic hernia (see the
box). A peritoneopericardial mesothelial
remnant, which represents the dorsal border
of the hernia on the lateral thoracic radio-
graph, can be seen in most affected cats.22
However, the absence of evidence of this
remnant does not rule out the hernia.

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

Other Diagnostic Procedures

Figure 6—Successive stages in the separation of the pleural cavities from
the peritoneal cavity of an embryo (transverse sections cranial to the trans-
verse septum) at (A) 5 weeks, (B) 6 weeks, (C) 7 weeks, and (D) 8 weeks.
Growth and development of the lungs, expansion of the pleural cavities,
and formation of the fibrous pericardium are also shown. (From Moore
KL [ed]: The Developing Human. Philadelphia, WB Saunders Co, 1988,
pp 159–169. Reproduced with permission.)
Other useful diagnostic procedures include
transhepatic ultrasonography,30 fluoroscopy of
the thorax,17 nonselective angiography,21,27
echocardiography,6,26,32 or positive-contrast
peritoneography.31 Pneumoperitoneography
and positive-contrast peritoneography can
yield false-negative results when herniated vis-
cera seal the diaphragmatic defect.47 An upper
gastrointestinal study, which is convenient

PERITONEOPERICARDIAL MESOTHELIAL REMNANT ■ CARDIAC DISPLACEMENT

The Compendium May 1996 Small Animal

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-

COMPUTED TOMOGRAPHY ■ MAGNETIC RESONANCE IMAGING

 Small Animal The Compendium May 1996

Your comprehensive
tion of peritoneopericardial diaphragmatic hernia led
guide to diagnostic to long-term survival in 22 of 25 cats.

ultrasonography Degree of Herniation

The degree of herniation ranges from minimal organ
Nautrup and Tobias displacement to major herniation of nearly all abdomi-
nal organs (with severe clinical signs).7,23 The liver and
gallbladder tend to herniate most frequently, followed
by small intestine, fatty tissue (e.g., omentum), and
spleen. The herniated organs may be able to slide back
and forth through the canal.16 This phenomenon ex-
plains why some patients’ clinical signs vary over time.

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
CALL OR FAX TODAY TO ORDER Surgical Approach
■ Peritoneopericardial
800-426-9119 • Fax: 800-556-3288 A ventral midline ap-
proach from the ster- mesothelial remnant22
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the Caribbean. Request international pricing.
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PORTAL HYPERTENSION
The Compendium May 1996
preferred for all congenital peritoneopericardial diaphrag-
matic hernias because it provides access to the entire di-
aphragm. This approach does make suturing more diffi-
cult, however, because the diaphragm is viewed from its
concave surface. Lateral thoracotomy is contraindicated.47
Surgical Procedure
The incision can be extended into the thorax if the
herniated organs cannot be reduced through the abdom-
inal approach. All herniated tissue is gently reduced into
the abdominal cavity, and all devitalized tissue is excised.
Incarcerated liver lobes may be infiltrated with adipose
tissue and may therefore need to be excised.14,24,29
After the edges of the defect are debrided without en-
try into the pleural cavity, a small hernia can be closed
with a single- or double-layer continuous suture pattern
commencing dorsally and proceeding ventrally.6 There is
no need to close the diaphragm and pericardium sepa-
rately.6,10 When tension could be a problem in large de-
fects, the pericardium is incised cranial to the diaphragm
and used as a flap or free graft to close the defect.47 It is
unnecessary to close the pericardium afterward.
If the pleural space was opened, pneumothorax must
be eliminated by thoracocentesis or tube thoracostomy
through the sutured diaphragm immediately after clo-
sure of the hernia.47 Prophylactic antibiotics are unnec-
essary unless the liver was injured or an abdominal vis-
cus was perforated.
Prognosis
Although most of the cats had a favorable outcome af-
ter surgical correction, two cats died shortly after the pro-
cedure. The causes of these deaths are unknown.20,21 Nev-
ertheless, correction is recommended in nearly all cases,
even those found incidentally. As mentioned, reduction
may be difficult in old animals, whose herniated organs
may have adhered to the heart or the pericardium.6
ACKNOWLEDGMENTS
The author thanks Simon König of the Institute of
Veterinary Anatomy and Lucio Palmieri of the Small
Animal Clinic of the University of Bern for preparing
the photographs. He thanks Gina Neiger-Aeschbacher,
DrMedVet, of the Small Animal Clinic of the Universi-
ty of Bern and Renate Vögtli-Bürger, DrMedVet, of
Kleintierpraxis Gundeli, Basel, for their comments.
About the Author
Dr. Neiger is affiiliated with the Small Animal Clinic, Uni-
versity of Bern, Bern, Switzerland. He is currently affiliat-
ed with the Gastroenterology Department of Inselspital
Bern, Bern, Switzerland.
REDUCTION ■ EXCISION ■ CLOSURE
Small Animal
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