Late onset Bochdalek hernia with intrathoracic herniation of abdominal contents and gastric perforation

A nineteen-year-old male patient presented with intermittent tachypnoea and abdominal pain for one month. No history of fever, vomiting, haematemesis or melaena. There was no previous history of trauma. Lab investigations were within normal limits.

Chest radiograph was taken as an initial imaging modality which revealed elevated left dome of diaphragm with large air-filled lucent structures in the left hemithorax. Mediastinal shift was noted to the right side. Fundic gas shadow was not seen under left dome of diaphragm.

Computed tomography (CT) revealed a large defect in the left dome of diaphragm with herniation of stomach, spleen, omentum and few large bowel loops into the thoracic cavity. The stomach was grossly distended with air fluid level within it. It was rotated along its long axis, suggestive of volvulus. There was no pneumatosis in bowel or stomach walls.

On exploratory laparotomy, a posterior diaphragmatic defect measuring ~ 6 cm was seen with intrathoracic migration of stomach, part of transverse colon and spleen. Two small perforations with surrounding pre-gangrenous changes were present in the anterior wall of the fundus of the stomach. The hernia was reduced with primary closure followed by peritoneal lavage and intercostal drainage tube insertion.

A Bochdalek hernia arises due to a developmental defect of the pleuroperi­toneal folds or due to non-fusion of the folds and transverse septum with the intercostal muscles. They comprise almost 90% of congenital diaphragmatic hernias and are found more commonly on the left side. A small minority are Morgagni hernia type which arise anteriorly. [1] Diaphragmatic paralysis, weak­ness and eventration without defect constitute dysfunction. Acute onset of respiratory distress is the usual presentation in the neonatal period while non-specific symptoms or asymptomatic presentation can occur in the older age group. [2]

Complications can include incarceration, trauma and strangulation of hollow viscera. These can resemble cardiovascular or gastrointestinal causes of chest and abdominal pain, few of which may need emergency surgery. The various modalities for diagnosis include chest radiograph, ultrasound, CT, MRI and fluoroscopy. Prenatal diagnosis is possible and ipsilateral lung hypoplasia can be a finding. Large defects can permit herniation of bowel loops into the thorax. [3] Features like multiplanar and 3-dimensional reconstruction by use of MDCT seem to aid the diagnosis of asymptomatic incidental Bochdalek hernias, thus making it the imaging modality of choice. [4]

Primary closure of defect by surgery is the treatment of choice in an emergency setting and in cases of trauma. Biologic meshes for hernia repair and laparoscopic approach have gained popularity in recent times. When suspicion of intestinal obstruction or volvulus is suspected as in this case, abdominal approach may be used. [5]

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