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Source publication
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 chr...
Context in source publication
Context 1
... chest tube was inserted on suspicion of hydropneumothorax. A chest radiograph following the chest tube insertion (Fig. 2) showed the tube positioned between the chest wall and the air collection and not draining any fluid, which raised the suspicion of congenital diaphragmatic hernia. After nasogastric (NG) tube insertion, the chest radiograph ( Fig. 3) showed the tip of the NG tube posi- tioned in the left side of her chest. A retrospective ana- lysis of the abdominal X-ray (Fig. 4) showed a triangular lucent area in her upper abdomen connected to her left chest cavity indicating a missed diaphragmatic ...
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Congenital diaphragmatic hernias are most common postero laterally which are called as Bochdalek hernias. They are very rare to occur in adults. Here we present a case of 50-year-old male who presented with acute respiratory distress with suspected diagnosis of hydropneumothorax which was later confirmed as left sided Bochdalek hernia. The defect w...
A congenital diaphragmatic hernia (CDH) occurs when the abdominal contents protrude into the thoracic cavity through an opening in the diaphragm. The main pathology lies in the maldevelopment or defective fusion of the pleuroperitoneal membranes. Delayed diagnosis in later childhood as in the index case reported here can lead to life-threatening co...
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Diaphragmatic hernias of Morgagni are anatomical defects in the anterior diaphragm that allow herniation of abdominal viscera into the thorax. They are the rarest of congenital diaphragmatic hernias and usually present in childhood with respiratory symptomatology. Adults are often asymptomatic or present with strangulation of visceral contents. We...
Citations
... Thus, it is often misdiagnosed or undiagnosed for long periods of time. 3 The diagnostic delay is significantly longer in patients with late-presenting CDH, and they require significantly more investigative procedures. 4 In our case, the patient presented with chronic weight loss and acute respiratory symptoms due to a suspected viral infection. ...
... However, approximately 5% are found after the neonatal period. [5] When the diaphragmatic hernia is small, it is protected by the liver on the right, and the spleen on the left, so often there are no symptoms for several months to years of life and patients often have normal chest x-ray. [5][6][7] Late-onset CDH is less common, and can present with various symptoms, such as cough, dyspnea, chest pain, frequent respiratory infections, abdominal pain, diarrhea, and vomiting. ...
... [5] When the diaphragmatic hernia is small, it is protected by the liver on the right, and the spleen on the left, so often there are no symptoms for several months to years of life and patients often have normal chest x-ray. [5][6][7] Late-onset CDH is less common, and can present with various symptoms, such as cough, dyspnea, chest pain, frequent respiratory infections, abdominal pain, diarrhea, and vomiting. In severe cases, patients can present with serious respiratory failure or cardiopulmonary failure. ...
... This makes diagnosis of CDH difficult and it is often mistaken for other conditions. [2,[5][6][7] The patient in this report did not have CDH diagnosed during obstetric ultrasound, and based on the history of no symptoms since birth we suspected a small diaphragmatic defect, which was later confirmed during operation. Since the defect was small, it was likely that the hernia was protected by the spleen so that the organs had not herniated through the defect. ...
Rationale:
Tension gastrothorax is a serious condition that can cause acute respiratory failure, which is mostly related to congenital diaphragmatic hernia (CDH) in pediatric cases. It is uncommon in late-onset CDH patients, and is difficult to diagnose due to atypical presentation. It is often misdiagnosed as tension pneumothorax or pleural effusion, leading to delayed treatment and potentially fatal outcome. In this study, we are reporting our experience of diagnosis and treatment of tension gastrothorax in a late-onset CDH patient.
Patient concerns:
A 2-year old boy presented to this hospital with severe dyspnea and abdominal pain that suddenly occurred while taking a bath.
Diagnosis:
Based on radiological findings we diagnosed tension gastrothorax.
Interventions:
Hernia reduction and diaphragmatic defect repair were performed under thoracotomy.
Outcomes:
After the operation, the patient's clinical symptoms and imaging findings improved. At 1-year postoperative follow up, the patient was well with normal chest x-ray findings.
Lessons:
Tension gastrothorax in late-onset CDH is a life-threatening condition that requires rapid diagnosis and treatment. When the diagnosis is unclear by chest x-ray, chest computed tomography should be performed to confirm the diagnosis. A nasogastric tube should be inserted whenever possible for diagnosis and gastric decompression. Although laparotomy is the most preferred approach, we recommend that surgeons consider taking a thoracotomy approach in unstable patients that cannot undergo gastric decompression before operation.
... The failure of closure of this foramen causes a persistent diaphragmatic defect, allowing abdominal viscera to be trapped in the thorax [1,6]. The absence of prenatal diagnosis and the belated diagnosis of BH can be explained by the protective role of liver or spleen which may occlude small diaphragmatic defects and prevent the bowel herniation during fetal development [8]. Although most CDHs present in first 24 hours of life, 5-25% of the patients may have a late presentation [3]. ...
We report a case of a 5-month-old female infant who presented with a cardiorespiratory distress and shock. After thoracic computed tomography (CT) scan, a right sided Bochdalek hernia was diagnosed with massive herniation of the abdominal viscera causing mediastinal shift. The girl underwent emergency laparotomy, which confirmed the right sided diaphragmatic hernia with herniation of small bowel and colon. After reduction of herniated contents, the defect in the diaphragm was closed. The patient had an uneventful post-operative cause. This case demonstrates that an undiagnosed Bochdalek hernia can appear with such a severe, life-threatening and misleading presentation.
... "Tension gastrothorax" as reported by other authors [2] is the likely cause of acute presentation in this case. Chest X-ray taken in this condition is very likely to be mistaken for hydropneumothorax due to the fluid level in the stomach, and this seems to be a common mistake in the emergency department [3]. The intercostal drain which was inserted for the apparent hydropneumothorax may have caused the gastric perforation in our case, leading to worsening of the condition. ...
... The gastrothorax and related intestinal herniation contribute to the common complaint of vomiting, which can be accompanied by abdominal pain and irritability [3]. A previously reported case in a 7-year-old described the left-sided gastrothorax as being initially diagnosed as a hydropneumothorax; presence of the patient's nasogastric tube in the left chest help re-direct the evaluation [4]. Gastric volvulus has also been identified as the presenting symptom of a previously undiagnosed CDH [5]. ...
Although congenital diaphragmatic hernia (CDH) primarily presents in either the prenatal or neonatal period, late presentation has a reported incidence of 2.5–25%. This case report describes an 8-month-old-male who presented to the emergency department with dehydration and a 24-h history of bilious emesis. Work-up led to the diagnosis of a left-sided Bochdalek CDH. He subsequently underwent laparoscopic diaphragmatic hernia repair with reduction of near-total length of incarcerated bowel. The patient had an uneventful recovery. Babies born with CDH are typically unstable at birth, and even with repair, the mortality rate remains high. However, in the case of delayed CDH diagnosis where there are no perinatal issues, surgical repair has very high success rates, provided that there are no complications regarding the delay. If there is not a high index of suspicion based on the patient's history and exam, delayed diagnosis and intervention with late CDH presentations can lead to complications which could otherwise be minimized. The purpose of this case report is to raise awareness and contribute to the growing knowledge about delayed CDH presentation among physicians and surgeons to facilitate early diagnosis and care of a morbid yet manageable condition.
... The aforementioned decedent falls into this category, providing a prime example of hidden mortality. A number of similar cases of otherwise apparently healthy patients, ranging in age at presentation from a few months to years and even decades, with abrupt symptom onset related to sudden herniation of abdominal viscera through the defect and into the thoracic cavity, have been reported (17)(18)(19)(20). Most patients with late-presenting CDH report upper quadrant pain, dyspnea, and vomiting, which occur either in one severe episode leading to medical investigation and diagnosis, or intermittently if herniation occurs and subsequently resolves without medical intervention (17)(18)(19)(20). ...
... A number of similar cases of otherwise apparently healthy patients, ranging in age at presentation from a few months to years and even decades, with abrupt symptom onset related to sudden herniation of abdominal viscera through the defect and into the thoracic cavity, have been reported (17)(18)(19)(20). Most patients with late-presenting CDH report upper quadrant pain, dyspnea, and vomiting, which occur either in one severe episode leading to medical investigation and diagnosis, or intermittently if herniation occurs and subsequently resolves without medical intervention (17)(18)(19)(20). ...
Congenital diaphragmatic hernia (CDH) is an uncommon condition in which the embryological elements of the diaphragm fail to fuse
completely, leaving a defect in the barrier separating the thorax from the abdomen. Although most cases are symptomatic at birth and
lead to prompt treatment, asymptomatic cases may go undetected, presenting later on as a result of sudden or exacerbated herniation
of abdominal contents into the thoracic cavity. Presented here is the sudden death of a 6-week-old girl. At autopsy, the abdominal organs
were found to be filling the left chest cavity, having herniated through a previously undetected posterior diaphragmatic hernia of Bochdalek.
The literature on CDH is reviewed, including discussion of the embryological origin, clinical presentation, diagnosis, and treatment
of the condition. Special emphasis is placed on the challenges posed by these late-presenting cases, particularly in their diagnosis and
management, highlighting the importance of developing more direct methods of detection for these very reasons.
Post-traumatic diaphragmatic hernia is a rare but life-threatening condition resulting from a traumatic injury to the diaphragm. We present a case of a 48-year-old man with a history of fall injury and a delayed presentation of a right-sided diaphragmatic hernia with subsequent bowel obstruction and perforation in a patient with a history of trauma and tuberculosis. The patient underwent exploratory laparotomy with manual reduction of the herniated bowel, primary repair of the diaphragmatic defect, and the creation of a double-barrel ileostomy. This case highlights the importance of considering traumatic diaphragmatic hernia in patients with a history of trauma presenting with abdominal symptoms. Timely diagnosis and surgical intervention are crucial in preventing serious complications associated with this condition.
Background
Congenital diaphragmatic hernia (CDH) is a scarce birth defect. It is called late-presenting CDH when symptoms are found after 1 month of life. The clinical manifestations of late-presenting CDH are diverse, among which the most fatal is the cardiac arrest caused by tension gastrothorax. The disease is rare, can easily lead to death owing to improper emergency treatment. This report illustrates the emergency treatment of late-presenting CDH with tension gastrothorax in three Chinese children.Case reports and managementThree children presented to emergency room with a sudden dyspnea, diagnosed accurately by x-ray or computed tomography. In case 1, the gastric tube could not be inserted at the first attempt, and the child cried incessantly. Cardiac arrest occurred when the gastric tube was re-inserted. After cardiopulmonary resuscitation and placement of a thoracic drainage tube, a large amount of gas and stomach contents were drained. Laparoscopic surgery was performed. The patient died of sepsis. In case 2, the gastric tube could not be inserted at the first attempt; consequently, emergency surgery was considered instead of retrying. After the patient was anesthetized, a gastric tube was successfully placed. Subsequently, a large amount of gas and gastric contents was drained, and thoracoscopic surgery was performed. The patient recovered evenly. In case 3, the gastric tube was successfully inserted at the first attempt; however, the vital signs were unstable due to poor drainage of the gastric tube. We injected 20 ml of iohexol into the stomach tube for angiography and dynamic chest film monitoring. After adjusting the position of the stomach tube, the stomach collapsed completely. Thoracoscopic surgery was performed. The patient recovered evenly.Conclusion
Early diagnosis is essential for children with late-presenting CDH complicated by tension gastrothorax. Fully collapsing the stomach is a key step in emergency treatment. In addition, gastric tube insertion is the first choice. In children with difficulty in gastric tube placement at the first attempt, the gastric tube can be placed under anesthesia, and emergency surgery performed simultaneously. Endoscopic surgery can be the first choice in cases of complete stomach collapse.
