Presentation
Severe epigastric pain at 32 weeks gestation with repeated vomiting. Unable to pass nasogastric tube into stomach.
Patient Data
Chest x-ray shows indistinct left hemidiaphragm with presence of gastric bubble and bowel loops over mid to lower zones of left hemithorax. Rightward mediastinal shift.
Large left posterolateral diaphragmatic defect associated with herniation of stomach, left sided bowel loops and mesenteric fat. Stomach is grossly distended with air-fluid levels whilst herniated bowel loops are collapsed. Gastric antrum and pylorus are displaced superiorly with respect to gastro-esophageal junction. Findings suggestive of diaphragmatic hernia - Bochdalek type complicated with gastric volvulus.
Mass effect is also evident with rightward mediastinal shift and compressive atelectasis of left lung.
Bilateral hydronephrosis, more significant on right side, likely related to extrinsic compression by gravid uterus.
Case Discussion
Emergency laparotomy for repair of diaphragmatic hernia and emergency Cesarean were performed in the same setting. Intra-operative findings confirmed Bochdalek hernia with obstructed stomach and non-dilated small bowel loops in left hemithorax.
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