Diaphragmatic hernia with closed-loop small bowel obstruction

Case contributed by Hoe Han Guan


Left chest pain and shortness of breath for 3 days. No history of trauma.

Patient Data

Age: 50 years
Gender: Male

Large defect seen at the posterolateral aspect of the left hemidiaphragm.
Spleen, small bowel loops and mesenteric fat passed via this large left hemidiaphragm defect into the left hemithoracic cavity results in significant mediastinal and cardiac shift to the right side. Small bowel loops are dilated within the left diaphragmatic hernia. The dilated small bowel loops seen in both left hemithorax and peritoneal cavity where transition point is seen within the left diaphragmatic hernia. The dilated small bowel loops have C shaped/U shaped configuration where beaking appearance is seen in transition point with mesenteric fat streakiness. Whirlpool sign of the mesentery is noted.

The cecum and terminal ileum are mobile and located in the right lumbar region. The distal ileum and the colon are collapsed and within the peritoneal cavity.

No pneumoperitoneum, intramural gas and portal venous gas to suggest bowel ischemia.

Left lower lobe of the lung is almost completely collapsed with minimal aeration of the left upper lobe.

Annotated images

Annotated image

Annotated images to show the diaphragmatic defect, herniated small bowel loops and spleen.

Case Discussion

Left diaphragmatic hernia (where the location of defect is suggestive of Bochdalek hernia) with significant mediastinal, tracheal and cardiac shift to the right side (under tension). Concurrent closed loop small bowel obstruction without CT evidence of bowel ischemia.

As there is no previous history of trauma or surgery, the presumed etiology of this diaphragmatic hernia is likely to be congenital.

Emergency surgical repair of the diaphragmatic hernia and small bowel obstruction performed. Intraoperatively, no bowel ischemia.

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