Congenital asymptomatic diaphragmatic hernias in adults: a case series

Diagnostic challenges in late-presentation congenital diaphragmatic hernia: A case study of a 10-month-old with respiratory symptoms

Congenital diaphragmatic hernia (CDH) is a developmental disorder in which the diaphragm, the muscle that separates the chest from the abdomen, does not close during prenatal development, allowing abdominal organs to herniate into the chest cavity. It occurs mainly on the left side (80%-85% of cases). CDH is often identified during prenatal assessment. However, instances of late-presenting CDH beyond infancy are exceedingly uncommon, contributing to frequent misdiagnosis and delayed therapeutic intervention. We present a case of a 10-month-old female with an uneventful antenatal and perinatal history who presented with respiratory distress and multiple episodes of vomiting. Her vital signs were stable upon arrival, but she was sent to the PICU due to hypoactivity, reduced oral intake, and agitation. After an urgent CT scan, a herniation of the small and large bowel loops into the right hemithorax was discovered, along with a defect in the right hemidiaphragm. This resulted in a pleural effusion on the right side, a partially collapsed left lung, and a mediastinal shift to the left. The diaphragmatic hernia was corrected through a lateral thoracotomy at the sixth rib with multiple interrupted sutures, and a chest tube was then inserted into the pleural space above the diaphragm following a smooth reduction of the bowl. This case highlights the importance of early diagnosis, appropriate clinical investigation, and treatment. A good prognosis can be anticipated by promptly discovering and examining the condition.

Previously undiagnosed Morgagni hernia with bowel perforation detected during repeat screening colonoscopy: A case report

BACKGROUND

Morgagni hernia (MH) is a form of congenital diaphragmatic hernia (CDH) characterized by an incomplete formation of diaphragm, resulting in the protrusion of abdominal organs into the thoracic cavity. The estimated incidence of CDH is between 1 in 2000 and 1 in 5000 live births, although the true incidence is unknown. MH typically presents in childhood and can be diagnosed either prenatally or postnatally. However, it can also be asymptomatic and carry the risk of developing into a life-threatening condition in adulthood.

CASE SUMMARY

A 76-year-old female with no history of prior abdominal surgeries presented for an elective colonoscopy for polyp surveillance. During the procedure, when approaching the hepatic flexure, the scope could not be advanced further despite multiple attempts. The patient experienced mild abdominal discomfort, leading to the abortion of the procedure. While in the recovery area, she developed increasing abdominal pains and hypotension. Urgent abdominal imaging revealed herniation of the proximal transverse colon through a MH into the chest with evidence of perforation. The patient underwent laparoscopic urgent colonic resection and primary hernia repair and was discharged uneventfully 2 d later.

CONCLUSION

A MH is a rare condition in adults that can present as a life-threatening complication of colonoscopy, even in patients with a history of uneventful colonoscopies. This case highlights the importance of considering congenital and internal hernias when faced with sudden and unexplained difficulties during colonoscopy. If there is a suspicion of MH, the endoscopist should halt the procedure and immediately obtain abdominal imaging to confirm the diagnosis.

Obstructed Descending Colon Mass Presented With Bochdalek Hernia: A Case Report

The adult Bochdalek hernia is one of the right-sided diaphragmatic hernias that less than 30 cases reported until now. Here, we report a 64-year-old female patient who presented with dyspnea, abdominal pain, and nausea. Primary imaging showed a right-sided diaphragmatic hernia that contained the liver and right colon. At first, the patient underwent a right posterior thoracotomy, and the diaphragmatic defect was repaired. After 2 days, abdominal peritonitis happened then a midline laparotomy was performed. Finally, it was clear that the main problem was the obstructed and perforated descending colon mass that was presented with Bockdalek hernia. Unfortunately, the patient passed away 2 days after the operation. It should be considered that an increase in intra-abdominal pressure like the presence of obstructed colon mass can cause this rare hernia and It is important to determine the reason for the presentation of the symptomatic Bochdalek hernia in adult patients.

Obstructed Bochdalek hernia in an adult

Congenital diaphragmatic hernia is a common neonatal anomaly. Presentation beyond childhood, however, is rare. We report, here, the case of a woman in her 50s who presented with an acutely obstructed posterolateral diaphragmatic hernia. The initial physical exam and radiological results could have led to an erroneous diagnosis of pneumothorax. We wish to emphasize the importance of having a high index of suspicion for this condition when cases with similar gastro-respiratory symptoms are encountered.

Case report: anaesthetic and surgical management of a diaphragmatic rupture with tension pneumothorax and iatrogenic bowel perforation in an undiagnosed Bochdalek hernia patient

BACKGROUND

Congenital diaphragmatic defects are rare, with most cases presenting in childhood. Diagnosis in adulthood is usually incidental or when symptoms develop. We present a case of a strangulated Bochdalek hernia complicated by possible tension pneumothorax and iatrogenic bowel injury in a healthy young male.

CASE PRESENTATION

A 23-year-old Chinese man initially presented with complaints of mild back pain and was discharged with symptomatic treatment. He presented again 3 days later, with dyspnea and left upper back pain and was haemodynamically unstable and hypoxic. A chest x-ray was reported as a moderately large left-sided pneumothorax with herniation of bowel into the left hemithorax. Needle decompression resulted in feculent fluid being aspirated with no resolution of symptoms. The patient required an immediate transfer to the operating theatre for surgical intervention of his left diaphragmatic rupture, complicated by visceral herniation and left tension pneumothorax, with accidental puncture of the herniated bowel. He underwent an emergent laparotomy with requirements for rapid lung isolation and continued aggressive resuscitation.

CONCLUSIONS

Patients with congenital diaphragmatic hernias may present in adulthood, either incidentally or emergently. In the well adult patient with good reserves, these initial symptoms may be mild, and may be symptomatically treated with no further workup. However, patients may deteriorate rapidly once their compensatory mechanisms are exhausted. This is the first reported case of a patient with diaphragmatic rupture and bowel herniation, complicated by iatrogenic tension pneumothorax. This rare case illustrates the speed at which a diaphragmatic rupture may progress, possible pitfalls and offers insights on how a misdiagnosis may be avoided.

Congenital diaphragmatic hernia in an 81-year-old female presenting as painless jaundice: A case report

Introduction and importance

Adult congenital diaphragmatic hernia (CDH) is rare and may present as an incidental finding in an asymptomatic individual.

Case presentation

We report the case of an 81-year-old female who presented to the ED with painless jaundice and bilirubin of 19.9 mg/dL. She was diagnosed with biliary obstruction secondary to a right-sided CDH. The patient underwent surgery, which resulted in the correction of her CDH and a downward trend in her bilirubin.

Clinical discussion

CDH usually presents in the newborn period with respiratory distress and can have a high mortality rate. Although CDH is most often associated with newborns, it can rarely present in adulthood, manifesting insidiously with a variety of signs and symptoms ranging from a mild cough to biliary occlusion.

Conclusion

CDH may be considered in the differential diagnosis when other investigations for respiratory or gastrointestinal complaints have been unrevealing.

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Congenital diaphragmatic hernia in an 81-year-old female

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Jaundice due to biliary obstruction secondary to congenital diaphragmatic hernia

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Morgagni hernia discovered in an elderly patient

A rare adult morgagni hernia mimicking lobar pneumonia

Morgagni hernia is the rarest form of congenital diaphragmatic hernia and is commonly found either in the first few hours of life or in antenatal period. It is less common in adult and is mostly diagnosed incidentally in an asymptomatic patient. Symptomatic adult cases are even rarer with a wide variety of symptoms. Here we report a patient with a one year history of chronic recurrent cough and dyspnea, who had been misdiagnosed as recurrent pneumonia before being recognized and treated as Morgagni hernia.

Thoracolaparoscopic repair of diaphragmatic hernias

Complex long-standing diaphragmatic hernia presenting in adults is often managed through an open approach. Minimal invasive approach by either laparoscopy or thoracoscopy is limited by its ability to tackle these complex hernias with large defects and thoraco-mediastinal adhesions. Thus, standard laparoscopic or thoracoscopic approach is associated with high conversion to open approach. We herein describe a novel combined thoraco-laparoscopic approach to repair complex diaphragmatic hernias in a series of three adults.

Sudden death after being in a bounce house: a late complication of congenital diaphragmatic hernia

A 3-year-old white female with no significant past medical history was found unresponsive and apneic after several hours of vomiting. The patient had reportedly felt unwell since jumping in a bounce house at a festival earlier in the day. After one hour of attempted resuscitation by EMS and hospital staff, the patient was pronounced deceased. On autopsy there was a 3 cm opening in the left posterolateral hemidiaphragm with the spleen, the stomach, and portions of the small and large bowel displaced into the left chest cavity, resulting in compression of both lungs and the heart to the right side of the chest. The right lung weighed 295 g while the left lung weighed 73 g. Histologic examination revealed atelectasis in the left lung and congestion in the right lung, the spleen, the stomach, and the bowel. The cause of death was ultimately ruled to be respiratory compromise and associated gastrointestinal complications due to diaphragmatic herniation of abdominal contents into the chest cavity. It is hypothesized that herniation occurred in this case secondary to increased intra-abdominal pressure from jumping in a bounce house, an etiology that we were unable to find elsewhere despite a thorough literature search.

Bochdalek hernias associated with intrathoracic kidney: A case report and systematic review of outcomes including renal function

Background: An intrathoracic kidney is a very rare form of ectopic kidney. Though increasingly recognized in the literature, impact on renal function is less well described. We report the case of a 67-year-old South Asian gentleman who presented with intrathoracic kidney and chronic kidney disease. We carried out a systematic review of the available literature on intrathoracic kidney, in order to characterize the typical clinical features, and describe likely clinical course and possible renal and extra-renal complications associated with this form of ectopia. Materials and methods: A structured search using PubMed identified all relevant published case reports from 1988 to 2018, with search restricted to papers in English, and to adult cases only (> 18 years of age). 124 records were identified, and after screening for eligibility, 34 case reports were analyzed. Results: Median age was 53.5 years, with no gender predominance. 68% (27/34) of cases were symptomatic. 29% (10/34) had a significant complication associated with their intrathoracic kidney, with 3 cases with either documented chronic or end-stage kidney disease. 26% (9/34) required surgical intervention. Conclusion: Though previously regarded as a benign entity, results from our systematic review, bearing in mind susceptibility to publication bias, suggests an appreciable risk of symptoms, complications, and in the minority a risk to kidney function. We recommend close biochemical and imaging surveillance of affected patients, with low threshold for intervention in those with renovascular stenosis, reflux, or hydronephrosis.

Diaphragmatic hernia with isolated shoulder pain evoked by surfeit

Bochdalek hernia in adult is extremely rare, so symptoms or indications of surgery are not reported enough. Here we report a case of small-sized Bochdalek hernia with isolated shoulder pain that resolved after surgical reduction of hernia. A 25-year-old man with diaphragmatic mass was referred to out-patient clinic. Chief complaint was an isolated left shoulder pain evoked by surfeit. Diaphragmatic hernia was suggested on chest computed tomography (CT) but it was not certain. So, video-assisted thoracic surgery (VATS) exploration was planned to clarify the diagnosis. The mass was proven to be the Bochdalek hernia and successfully restored into abdominal cavity. There were no postoperative complications and isolated shoulder pain disappeared clearly.

Morphological Characterization of Diaphragm in Common Squirrel Monkey (Saimiri sciureus)

The wall of the diaphragm can be affected by congenital or acquired alterations which allow the passage of viscera between the abdominal and chest cavities, allowing the formation of a diaphragmatic hernia. We characterized morphology and performed biometrics of the diaphragm in the common squirrel monkey Saimiri sciureus. After fixation, muscle fragments were collected and processed for optical microscopy. In this species the diaphragm muscle is attached to the lung by phrenopericardial ligament. It is also connected to the liver via the coronary and falciform ligaments. The muscle is composed of three segments in total: 1) sternal; 2) costal, and 3) a segment consisting of right and left diaphragmatic pillars. The anatomical structures analyzed were similar to those reported for other mammals. Histological analysis revealed stable, organized muscle fibers with alternation of light and dark streaks, indicating transverse striation.

Acute Bowel Obstruction in a Giant Recurrent Right Bochdalek's Hernia: A Report of Complication on Both Sides of the Diaphragm

Context:

Diagnosis of congenital Bochdalek's hernia (BH) in adulthood is extremely rare and requires a fastidious surgical repair, the failure of which might result in a recurrence with severe complications. We report a rare case of a giant, right BH that recurred after surgical repair and was complicated with complete bowel obstruction.

Case Report:

A 51-year-old Saudi male, with past surgical history of laparotomy that failed to repair BH, presented to the emergency room with severe abdominal pain, vomiting, and hypovolemic shock. Computerized tomography (CT) showed an unusual picture of closed-loop bowel obstruction above and below the diaphragm. We carried out laparotomy and thoracotomy that achieved lysis of adhesions, reduction of bowel, and repair of diaphragmatic defect.

Conclusion:

Acute presentation of complicated BH poses a formidable challenge because of its rarity and complexity. The preferred approach for elective repair of adult BH is debatable, where surgeons—guided by hernia type and biased by their experience—recommend either laparotomy or thoracotomy. Nevertheless, a complicated, giant, recurrent BH typically requires both laparotomy and thoracotomy.

Chest X-ray findings in late-onset congenital diaphragmatic hernia, a rare emergency easily misdiagnosed as hydropneumothorax: a case report

INTRODUCTION

Late-onset congenital diaphragmatic hernia is a rare anomaly with misleading symptoms and signs.

CASE PRESENTATION

We describe the case of a 7-year-old Middle Eastern girl who presented with acute nonspecific abdominal symptoms and respiratory distress of 2 days' duration after sustaining a blunt trauma on her left chest wall on a background of chronic ill-defined left chest pain of 2 weeks' duration. Her initial chest radiograph showed an air-fluid level, which was thought to be a hydropneumothorax, so a chest tube was inserted and was shown to be positioned between the chest wall and the air collection; therefore, a nasogastric tube was inserted and it was positioned in the left chest cavity so the diagnosis of late-onset congenital diaphragmatic hernia was made. On retrospective analysis of the first abdominal X-ray, it showed a subtle lucent area that was triangular in shape and continued with the chest cavity, which indicates a sign of diaphragmatic hernia. In addition, the next unusual point was the nonvisualization of the diaphragm, which should be reported in any abdominal X-ray. An exploratory laparotomy was performed on our patient using a left-sided subcostal incision; the operative findings revealed a very small posterior rim of the diaphragm and a hypoplastic left lung. Her stomach, spleen, and left colon with the omentum were in the left side of her chest. She made an uneventful recovery postoperatively and was discharged after 1 week.

CONCLUSIONS

Gastric and intestinal gas shadow distribution provides an important marker in the diagnosis of late-onset congenital diaphragmatic hernia and should be sought for in every case of suspected congenital diaphragmatic hernia in addition to noting the position of the nasogastric tube in the chest cavity.

Transabdominal robotic repair of a congenital right diaphragmatic hernia containing an intrathoracic kidney: a case report

Bochdalek diaphragmatic hernia is a rare condition and is typically diagnosed prior to adulthood. Furthermore, right-sided defects are also uncommon due to the location of the liver, but can contain colon, omentum, small bowel, or rarely the kidney. Minimally invasive laparoscopic and thoracoscopic diaphragmatic hernia repairs are associated with improved outcomes when compared to open approaches-recently, robotic-assisted repairs have been performed in children with no morbidity and minimal complications. We report a case of an 80-year-old female who presented with an enlarging right-sided Bochdalek hernia containing an acquired intrathoracic kidney that was repaired using a robotic-assisted laparoscopic transabdominal approach with mesh placement. In this case, the robotic platform's advantages included excellent visualization of the posterolateral defect and efficient suturing during mesh placement. This approach is a viable option for skilled minimally invasive surgeons; however, further studies are warranted to investigate its utility in the management of diaphragmatic hernia repair.

Radiological diagnosis of congenital diaphragmatic hernia in 17th century Korean mummy

Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm resulting in pulmonary sequelae that threaten the lives of infants. In computed tomography (CT) images of a 17th century middle-aged male mummy (the Andong mummy), we observed that the abdominal contents had protruded into the right thoracic cavity through the diaphragmatic defect, accompanied by a mediastinal shift to the left. On autopsy, the defect in the right posterolateral aspect of the diaphragm was reconfirmed, as was the herniation of the abdominal organs. The herniated contents included the right lobe of the liver, the pyloric part of the stomach, a part of the greater omentum, and the right colic flexure connecting the superior part of the ascending colon and the right part of the transverse colon. Taking our CT and autopsy results together, this case was diagnosed as the Bochdalek-type CDH. Herein we make the first ever report of a CT-assisted diagnosis of a pre-modern historical case of CDH. Our results show the promising utility of this modality in investigations of mummified human remains archaeologically obtained.

Incidentally detected diaphragmatic hernia mimicking angina pectoris with Tc-99m MIBI myocardial perfusion imaging

In recent years ^99mTechnetium methoxy-isobutyl-isonitrile (^99mTc MIBI) is widely used in the evaluation of myocardial perfusion imaging (MPI). In this imaging protocol besides the cardiac evaluation, numerous other organs are included in the field of view. ^99mTechnetium MIBI is taken up in all metabolically active tissue in the body except for the brain. Extracardiac uptake patterns as benign or serious conditions can be revealed during the MPI. In the imaging protocol, we should be aware of distribution of this radiotracer in order to recognize the abnormal uptake. Here in, we present a large diaphragmatic hernia, seemed as a mirror vision of myocardium that was determined incidentally during the MPI with ^99mTc MIBI.