Large right diaphragmatic hernia

Case contributed by Dr Margaret Nguyen

Presentation

Chronic cough on a background of asthma. No history of trauma.

Patient Data

Age: 17
Gender: Female
X-ray

Chest x-ray demonstrates marked elevation of the right hemidiaphragm with a loop of colon interposed anterior to the liver, which is referred to as Chilaiditi's sign.

Fluoroscopy

CT chest demonstrates herniation of the intra-abdominal contents into the right thoracic cavity to the level of T2. The entire left lobe of the liver, the majority of the right lobe of the liver, the gall bladder, porta hepatitis, hepatic flexure, descending colon, caecum and distal ileum and proximal duodenum are located in the right thoracic cavity. This favours a large right diaphragmatic hernia.

There is significant compressive atelectasis of the right lung. There is leftward shift of the mediastinal contents and trachea. There is reduced calibre of the right atrium however the great vessels remain patent. No mediastinal mass or lymphadenopathy.

X-ray

Case Discussion

This case demonstrates a large right diaphragmatic hernia which was likely acquired given previous chest x-rays were normal. The patient had a history of poorly controlled asthma and raised intra-abdominal pressure from persistent cough may have provoked the diaphragmatic rupture.

The patient proceeded to have an emergency bronchoscopy, laparotomy and repair of the  right diaphragmatic hernia.

Her post-operative chest x-ray reveals restoration of the normal anatomical position of the intra-abdominal organs and right hemidiaphragam.

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Case information

rID: 53677
Case created: 30th May 2017
Last edited: 26th Jun 2017
System: Chest
Inclusion in quiz mode: Included

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