Presentation
Teenager admitted to ER with excruciating pain after a track and field excercise at school
Patient Data
AP- radiograph shows apparent elevated hemidiaphragm and a large gastric bubble with air-fluid level adjacent to the left heart border with positive mass effect and mediastinal shift to the right as well as compression of the boardering lung parenchyma. No pleural effusion or consolidation, no evidence of pneumothorax. No rib fracture.
The lateral radiograph taken an hour later shows a newly placed NGT with a loop configuration in the gastric corpus which lies intrathoracically. Again, air-fluid level and no apparent pneumothorax visible. Normal alignment of the vertebrae.
Non-contrast CT nicely demonstrates a huge gap in the left hemidiaphragm medially and dorsally with consecutive herniation of a large portion of the stomach into the thoracic cavity. The stomach abutts and mildly compresses the left heart with moderate midline shift of the mediastinum. Compression and discrete atelectasis of the left lower lung zone. NGT in place.
Splenic malrotation with the hilum pointing upwards towards the hernia, most likely in keeping with the prolapsed stomach and consecutive upwards pull of neighboring abdominal structures.
The rest of the visualized thorax and abdomen is unremarkable, particularly no evidence of diaphragmatic rupture, no free fluid, no hematoma, no pneumothorax, no pneumoperitoneum.
CONCLUSION:
Congenital Bochdalek hernia with herniation of large parts of the stomach into the chest cavity.
No traumatic diaphragmatic rupture.
Case Discussion
Intraoperative findings confirmed the congenital nature of the hernia and no evidence of a traumatic diaphragmatic rupture. However, surgery was rather urgent since the stomach wall showed signs of hypoperfusion due to the pressure on the wall against the edge of the diaphragm. Additionally, there was evidence of partial splenic herniation intraoperatively. Both organs were repositioned correctly and the hernia was subsequently closed with surgical sutures.
This case nicely demonstrates the prolapsing of organs through a pre-exsisting weak spot, in this case a congenital Bochdalek hernia, due to increased intraabdominal pressure, in this case brought about by physical activity.
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