A 20-year-old man presented with a 1 month history of intermittent dyspepsia and abdominal pain, as well as abdominal distention in the previous 24 hours before attending the hospital.
Blood tests and colonoscopy were unremarkable. No history of recent fever, traumatic injuries or vomits.
Abdominal radiography one month earlier on the onset of the symptoms was normal. (Fig. 1)
Abdominal ultrasound revealed a significant volume of ascites.
Due to the amount of the ascites and the history of abdominal pain, a computed tomography (CT) scan was performed after the administration of intravenous contrast, revealing a diaphragmatic hernia occupying the lower 2/3 of the left hemithorax, which included the entire stomach, spleen, colon (splenic flexure) and pancreatic tail. The celiac trunk and remaining segments of the pancreas appeared displaced cranially and to the left as a result of the displacement of the other organs. (Fig. 2) CT also revealed retained stomach contents and an air-fluid level consistent with gastric outlet obstruction.
Bochdalek hernia (BH) is the most common type of congenital diaphragmatic hernia, accounting for 90% of these hernias . BH is more common on the left side (85%) .
Late presenting congenital diaphragmatic hernia poses a considerable diagnostic challenge, since this diagnosis in the adult age is extremely rare; being mostly diagnosed during the neonatal period.  These BH are commonly misdiagnosed, due to their lower prevalence and symptoms.
BH is caused by failure of the posterolateral diaphragmatic foramina to fuse properly. Minor defects are not associated with deficits in lung development and may be asymptomatic until herniation of abdominal contents into the thoracic cavity occurs, with respiratory consequences. Late presentation may be explained by delayed rupture of peritoneal sac containing the viscera or plugging of hernia defect by solid organ due to raised abdominal pressure . If symptomatic, the most common presentation is thoracic and abdominal pain, respiratory stress, and bowel obstruction.
Differential diagnosis includes diaphragmatic rupture and Morgagni hernia. History of recent trauma is the cornerstone to allow a confident diagnosis of diaphragmatic rupture. Morgagni hernia is a congenital diaphragmatic hernia similar to BH but has an anteromedial location, usually on the right side.
CT is the most accurate modality for BH diagnosis and content evaluation, especially the smaller herniations .
The management of BH includes reduction of hernial contents to the peritoneal cavity and repair of the diaphragmatic defect .
The patient was subjected to laparotomy that revealed a small defect on the posterior diaphragm and dark punctate foci covering the stomach wall, indicative of early necrosis. (Fig. 3-4)
The surgical team proceeded to reduction and surgical repair of the hernia without complications.
Written informed patient consent for publication has been obtained.
 Cannon C, Dildy GA, Ward R, Varner MW, Dudley DJ. A population-based study of congenital diaphragmatic hernia in Utah: 1988-1994. Obstet Gynecol. 1996;87:959–63 (PMID: 8649706).
 Ahrend TR, Thompson BW. Hernia of the foramen of Bochdalek in the adult. Am J Surgery 1971;122:612–5 (PMID: 5112067)
 Matsudera S, Nakajima M, Takahashi M, Muroi H, Kikuchi M, Shida Y, et al. Laparoscopic surgery for a Bochdalek hernia triggered by pregnancy in an adult woman: a case report. Int J Surg Case Rep. 2018;48:10–5 (PMID: 29763850)
 Chatterjee S., Mitra A., Sarkar S., Prasad S. Acute intestinal obstruction: a rare presentation of left sided adult congenital diaphragmatic hernia. Hellenic J. Surg. 2015;87(5):427–429.
 Eren S, Ciris F. Diaphragmatic hernia: diagnostic approaches with review of the literature. Eur J Radiol 2005;54:448–59 (PMID: 15899350)
 Patle N.M., Tantia O., Prasad P., Das P.C., Khanna S. The management of Bochdalek hernia includes reduction of hernial contents to the peritoneal cavity and repair of the diaphragmatic defect. Indian J. Surg. 2013 Jun;75(Suppl. 1):303–304. Epub 2012 Jul 12.
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