Nasogastric feeding tube in right main bronchus? Bochdalek Hernia the missing piece of puzzle

Clinical History

A 61 year old woman presented with pneumonia and respiratory failure. She was intubated and ventilated due to worsening dyspnea. Chest X-ray after nasogastric tube insertion showed tube projecting over the anatomical area of the right main and right lower lobe bronchi. Multiple attempts of nasogastric tube insertion showed similar findings (Fig1). CT revealed diagnosis.

Imaging Findings

CT Abdomen and Pelvis with Oral and IV contrast showed a big defect in the right part of the diaphragm, right of the midline, containing herniated fat and stomach. The tip of the nasogastric tube is seen within the stomach, however the stomach is located at the right side of the chest due to the big hiatus hernia. Bilateral pleural effusion - right greater than left - associated with bilateral dependent opacities consistent with atelectasis versus consolidation. No pneumothorax was seen.

Discussion

Diaphragmatic hernias are either congenital or traumatic. Bochdalek hernia (BH) is a type of congenital diaphramatic hernia (CDH). CDH are caused by defect in the diaphragm musculature, which has been described in the history about 400 years ago. These CDH are described as various types depending upon the site of anatomical defect. If the defect is in posterior-lateral aspect of diaphragm it is called as Bochdalek hernia, which was named in the honor of professor Victor Alexander Bochdalek, who was a professor of anatomy at Prague in 1848 who originally described this condition [1]. During fetal development diaphragm develops from septum transversum, it divides the abdominal structures from thoracic cavity.The pleuroperitoneal folds fuse with septum transversum to complete formation of diaphragm, the defect in the fusion results in diaphragmatic hernia. Bochdalek hernia is a relatively rare finding, seen in 1 in 3000 to 4000 live births. The majority of them are depicted in childhood, but they can also rarely be seen in adults. In a study based on 13.138 cases, the incidence of Bochdaleck hernia in adults was 0.17% as reported by Mullin et al [2].
Diagnosis of BH is difficult as it can have a varied presentation. The patient can be asymptomatic and BH can be a finding on auscultating the chest where bowel sounds are heard or can present with severe abdominal pain and signs of intestinal obstruction hence a high index of suspicion is necessary.When presented with abdominal pain and distention, they have a tendency to be seen more on the left side and seen more common in males [3]. The clinical signs which guide towards diagnosis of BH were described by Fingerhut et al and consist of postprandial respiratory symptoms, abdominal or chest symptoms exacerbated by supine position or physical exertion and abnormalities seen in radiographic imaging in supine position [4, 5]. There are different imaging modalities available to aid making the diagnosis, plain chest X-ray which may show intestines in the thorax, CT scan in cases of traumatic hernia where the site of injury can be visualized.
The management of BH is surgical. The surgical techniques vary and have changed over the year from traditional laparotomy to laparoscopic surgery. BH was successfully operated in 1901 by Aue [6], while laparoscopic repair was performed by Al-Emadi [7] for the first time in 1998. The approach for the repair depends on the presentation, most of them are done as elective repair but emergency laparotomies are also conducted for the strangulated hernias.

Differential Diagnosis List

Final Diagnosis

Right sided Bochdalek Hernia

URL:	https://www.eurorad.org/case/12951
DOI:	10.1594/EURORAD/CASE.12951
ISSN:	1563-4086