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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 80-82

Unusual presentation of Bochdalek hernia in an adult


Department of Pulmonary Medicine, Narayana Medical College, Nellore, Andhra Pradesh, India

Date of Web Publication26-Mar-2019

Correspondence Address:
Karanam Gowrinath
Professor, Department of Pulmonary Medicine, Narayana Medicine College, Nellore, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_34_18

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  Abstract 


Left-sided Bochdalek hernia (BH) containing bowel loops and kidney in an adult is very rare and difficult to suspect if the symptoms are mild and non-specific. BH may also cause diagnostic confusion if clinical examination and routine postero-anterior chest radiograph findings mimic lung disease like pleural effusion. We report the case of an adult patient with BH who presented with radiographic appearance mimicking pleural effusion caused by the configuration of omentum with bowel loops in the left hemithorax. A lateral chest radiograph or chest ultrasound may help to avoid misdiagnosis and avoid management errors.

Keywords: Bochdalek hernia, Kidney, Omentum, Pleural effusion


How to cite this article:
Gowrinath K, Nizami MI. Unusual presentation of Bochdalek hernia in an adult. J Clin Sci Res 2018;7:80-2

How to cite this URL:
Gowrinath K, Nizami MI. Unusual presentation of Bochdalek hernia in an adult. J Clin Sci Res [serial online] 2018 [cited 2019 Sep 17];7:80-2. Available from: http://www.jcsr.co.in/text.asp?2018/7/2/80/254976




  Introduction Top


In adults, congenital posterolateral diaphragmatic hernia, also known as Bochdalek hernia (BH), containing abdominal viscera is rare and difficult to suspect if symptoms are non-specific and mild. In about 25% cases of congenital diaphragmatic hernia, the radiographic findings may be misinterpreted as pleural effusion or pneumothorax particularly with herniation of stomach, omentum and spleen.[1] We report a rare case occurrence, of BH-containing bowel loops, and kidney in an adult male who presented with clinico-radiologic features suggestive of a large left-sided pleural effusion.


  Case Report Top


A 30-year-old non-smoking male was referred to us for the evaluation of left-sided pleural effusion. The patient has been complaining of vague chest pain and breathlessness on moderate activity for the past 2 years. He also complained of nausea. He had been using proton-pump inhibitors (oral omeprazole) at his place of domicile for the same. There were no other significant illnesses in the past. Physical examination was unremarkable. Chest examination showed dull note to percussion and absent breath sounds all over left hemithorax except in the infraclavicular area. Other systems were clinically normal. Laboratory examination was unremarkable. A posteroanterior (PA) chest radiograph [Figure 1] done outside was suggestive of a large left-sided pleural effusion. However, left lateral chest radiograph [Figure 2] showed radiolucent areas within the opacity in PA chest radiograph. Ultrasonography of chest showed collapsed left lung and no free fluid. Plain computed tomography (CT) of the chest [Figure 3] revealed omental fat with bowel loops configured like upper level of pleural effusion, and a contrast-enhanced CT [Figure 4] showed small and large intestine loops, spleen and kidney as a part of Bochdalek hernia (BH) in the left hemithorax. Patient was referred to the surgical service for left diaphragmatic hernial repair.
Figure 1: Chest radiograph (postero-anterior view) suggesting a large left-sided pleural effusion with shift of mediastinum to opposite side

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Figure 2: Left lateral chest radiograph showing radiolucent areas

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Figure 3: Plain computed tomography of chest showing omental fat with bowel loops simulating the upper level of pleural effusion

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Figure 4: Contrast-enhanced computed tomography of the chest showing intestinal loops, spleen and kidney in the left hemithorax

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  Discussion Top


In adults, BH-containing abdominal viscera may often manifest with abdominal or chest pain or both with nausea and/or vomiting; about 30% may present acutely with strangulated or gangrenous viscera.[2] In our case, the patient had chest discomfort, exertional breathlessness and nausea. Most cases of asymptomatic adult BH are small containing fat or omentum, and large BH-containing small and large intestines, spleen and kidney with only minor symptoms are very rare.[3] In diaphragmatic hernia, the routine PA chest radiograph may be normal or may have appearance mimicking a pleural effusion, hydropneumothorax, tension pneumothorax, atelectasis, pulmonary sequestration and foreign-body aspiration.[4] In our case, BH was not suspected initially as the symptoms were nonspecific, and the clinico-radiologic findings were also suggestive of pleural effusion. The contents of left-sided BH include colon, stomach, spleen, small intestine, omentum, pancreas and adrenal gland,[5] and in our case, the kidney was present, in addition, as a very rare finding. Routine PA chest radiograph can often reveal diaphragmatic hernia if it contains hollow viscus or may lead to further diagnostic tests like CT of chest or abdomen which can diagnose a diaphragmatic hernia. CT is considered as the most accurate diagnostic tool to determine contents of a diaphragmatic hernia, and multislice CT of the chest with coronal and sagittal reconstructions is the most useful imaging technique with high sensitivity for soft tissue; magnetic resonance imaging is reserved for cases where the diagnosis is still doubtful.[6] In our case, the intrathoracic configuration of omental fat was responsible for pleural effusion like appearance in the PA chest radiograph and this was evident in the CT of the chest. Earlier of an adult patient with BH-containing omentum mimicking, a left-sided pleural effusion even in a lateral decubitus chest radiograph.[7] In another case report of BH in an 18-year-old male with bowel loops and hypoplastic left lung who presented with respiratory symptoms simulated an encysted pleural effusion; even diagnostic pleural aspiration was attempted.[8]

A lateral chest radiograph should be done routinely for better evaluation of a unilateral pleural effusion suspected through PA chest radiograph alone. Chest ultrasound examination is more useful as it can also be done bedside to exclude pleural effusion quickly and help to prevent thoracocentesis related potential complications such as bowel perforation or enterocutaneous fistula. All cases of BH-containing abdominal organs should undergo surgery irrespective of the severity of clinical presentation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bagłaj M, Dorobisz U. Late-presenting congenital diaphragmatic hernia in children: A literature review. Pediatr Radiol 2005;35:478-88.  Back to cited text no. 1
    
2.
Swain JM, Klaus A, Achem SR, Hinder RA. Congenital diaphragmatic hernia in adults. Semin Laparosc Surg 2001;8:246-55.  Back to cited text no. 2
    
3.
Kinoshita F, Ishiyama M, Honda S, Matsuzako M, Oikado K, Kinoshita T, et al. Late-presenting posterior transdiaphragmatic (Bochdalek) hernia in adults: Prevalence and MDCT characteristics. J Thorac Imaging 2009;24:17-22.  Back to cited text no. 3
    
4.
Zaleska-Dorobisz U, Bagłaj M, Sokołowska B, Ładogórska J, Moroń K. Late presenting diaphragmatic hernia: Clinical and diagnostic aspects. Med Sci Monit 2007;13 Suppl 1:137-46.  Back to cited text no. 4
    
5.
Thomas S, Kapur B. Adult bochdalek hernia – Clinical features, management and results of treatment. Jpn J Surg 1991;21:114-9.  Back to cited text no. 5
    
6.
Eren S, Ciriş F. Diaphragmatic hernia: Diagnostic approaches with review of the literature. Eur J Radiol 2005;54:448-59.  Back to cited text no. 6
    
7.
Lee EJ, Lee SY. “Fluid” shift on chest radiography: Bochdalek hernia. CMAJ 2010;182:E311-2.  Back to cited text no. 7
    
8.
Sarkar S, Maji A, Saha K, Jash D. Congenital Bochdalek's hernia in a 18-year-old boy. J Assoc Chest Physicians 2013;1:62-4.  Back to cited text no. 8
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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