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Bochdalek Hernia in Asymptomatic Adults: a Case Report of Radiological Importance AM Aziza, R Yasminb, MA Haquec

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Bochdalek Hernia in Asymptomatic Adults: a Case Report of Radiological Importance AM Aziza, R Yasminb, MA Haquec Journal of Bangladesh College of Physicians and Surgeons Vol. 36, No. 4, October 2018 Bochdalek Hernia in Asymptomatic Adults: A Case Report of Radiological Importance AM AZIZa, R YASMINb, MA HAQUEc Summary: mediastinal shifting to right side in a young lady, who Congenital Diaphragmatic Hernias (CDH) is a rare was asymptomatic throughout the life and referred to us entity with incidence of 1:3000 live births. Late for evaluation of incidental findings of chest X-ray presentation is unusual and in most cases is diagnosed abnormality who was suffering from cholelithiasis. The in adolescents or early childhood. Asymptomatic surgical approach for the resolution of this pathology is diaphragmatic hernia in the absence of trauma is very variable and it depends on the presence and severity of rare in adults. The finding of CDH in adults is mostly visceral complications. incidental. Left sided hernia i.e. Bochdalek hernia is Keywords: Congenital diaphragmatic hernia, Bochdalek more common. It is more commonly associated with other hernia, diaphragm. anomalies. The morbidity and mortality are mainly due to pulmonary hypoplasia. We report a case of CDH, (J Bangladesh Coll Phys Surg 2018; 36: 175-178) posterolateral defect (Bochdalek type), with mild DOI: http://dx.doi.org/10.3329/jbcps.v36i4.38188 Introduction: failure.8,9 It is rarely seen in adults, with little more Congenital Diaphragmatic Hernia (CDH ) is a term than 100 cases reported in the literature.10 Traumatic applied to a variety of congenital birth defects that diaphragmatic hernia can present in any age group.11 involve abnormal development of the diaphragm Asymptomatic large Bochdalek hernia is quite rare through which protrusion of abdominal viscera into the among adults.12 These patients usually present with 1 chest cavity occur. CDH is classified according to difficulty in breathing or pneumonia like symptoms the location of the protrusion, including in hiatal hernia, or gastrointestinal symptoms and end up being 2 Morgagni-Larrey hernia and Bochdaleck hernia. diagnosed with CDH.13 CDH should be included in the Bochdaleck hernia was first described in 1848 by the differential diagnosis of pneumonia and other Czechoslovakian anatomist, Vicent Alexander respiratory or gastrointestinal diseases.14,15 A definite 3 Bochdalek. It is a posterior congenital defect of the diagnosis can be made by CT alone because of its diaphragm caused by a lack of closure of the characteristic features.12 Here is a case of an pleuroperitoneal cavity between the eighth and tenth asymptomatic adult with a large left sided Bochdalek week of embryonic life. 70% to 90% of cases occur hernia. on the left.4 It usually presents in childhood with an incidence ranging from 1:4000 to 1:7000 newborns5 Case Report: and more frequent in male.6,7 Patients usually presents A 25 year old housewife hailing from a rural community during the first hours after birth with severe respiratory presented to surgery department for elective cholecystectomy. As a part of pre-operative assessment a. Dr. Ahmad Monjurul Aziz, Junior Consultant, Dept. of Medicine, basic investigations including chest x-ray was done. Dhaka Dental College Hospital, Dhaka. Then she took subsequent two courses of antibiotics b. Dr. Rubina Yasmin, Professor & Head, Dept. of Medicine, Dhaka for radiological abnormality in left lung. But her Dental College Hospital, Dhaka. radiological abnormalities didn’t improved. Then she c. Dr. Md. Azharul Haque, Dept. of Medicine, Dhaka Dental College was referred to our department for further evaluation Hospital, Dhaka. of that radiological abnormalities which showed a Address of Correspondence: Dr. Ahmad Monjurul Aziz, Junior Consultant, Dept. of Medicine, Dhaka Dental College Hospital, Dhaka. nonhomogeneous opacity occupying left mid and Phone: +8801715040286, E-mail: [email protected] lower zone with mediastinal shifting was found in the Received: 28 September, 2017 Accepted: 2 June, 2018 left lung in chest X-ray [Figure-1]. Journal of Bangladesh College of Physicians and Surgeons Vol. 36, No. 4, October 2018 Fig.-1: X-ray Chest Posterior-Anterior view Fig.-2: Computed Tomography of chest showing left showing nonhomogeneous opacity occupying left hemi-diaphragmatic defect with herniation of stomach mid and lower zone with mediastinal shifting to right and coils of intestine into the thorax, compression of side. the left lung and mild mediastinal shifting On query she denied any respiratory complaints. She As she was asymptomatic with normal laboratory had no history of fever, abdominal pain, any bowel investigations and such radiological findings, we further abnormality or any other significant symptoms. She investigate her to find out other possibilities including had no significant past history suggestive of respiratory congenital anomalies. disease including tuberculosis. General examination A CT scan of the chest with abdominal screening was revealed only mild anaemia with normal respiratory advised. Computed tomography with oral contrast rate. Chest examination revealed mildly restricted demonstrated a left hemi-diaphragmatic defect with movement, resonant percussion note with reduced herniation of stomach and coils of intestine into the breath sound in left lower zone. Laboratory thorax, compression of the left lung and mild investigation results showed no abnormalities and mediastinal shifting suggestive of diaphragmatic hernia- ultrasonogram of whole abdomen showed only Bochdalek’s. Finally the patient was referred to thoracic cholelithiasis. surgeon for surgical correction of the defect. Fig.-3: Computed Tomography of chest with oral contrast Fig.-4: Computed Tomography of chest showing showing left hemi-diaphragmatic defect with herniation herniation of stomach and coils of intestine into the left of stomach and coils of intestine into the thorax. side of chest with mild mediastinal shifting to right side. 176 Bochdalek Hernia in Asymptomatic Adults: A Case Report of Radiological Importance AM AZIZ et al. Discussion: be complicated and present as intestinal obstruction A Bochdalek hernia is a congenital defect of the or volvulus.25,26 So for these variable presentations, diaphragm located in the posterior insertion. This is diagnosis of Bochdalek hernia by only X-ray films are caused by a lack of closing of the pleuroperitoneal not always easy. cavity by incomplete diaphragmatic development A computed tomography (CT) scan is the radiological before the intestine returns to the abdomen from the investigation that allows the highest accuracy for a yolk sack between weeks 8 and 10 of gestation. If correct diagnosis. It provides a precise assessment of hernia formation precedes lung development, the anatomical relationships between the viscera, and pulmonary hypoplasia may occur with severe congenital malformations, as in our cases. The typical respiratory compromise at birth. The diaphragmatic findings of the CT scan are the presence of fat or soft defect may be congenital or acquired. The most tissue over the upper surface of the diaphragm frequent cause of herniation of the abdominal viscera characteristically posterolateral, a mass adjacent to the in adults seems to be trauma (blunt or penetrating) diaphragmatic defect, and a continuous density over followed by iatrogenic (esophago-gastric surgery for and under the diaphragm’s discontinuity.24 esophagus cancer or gastric cancer).17 In adults, this defect is uncommon, the lung in most cases develops In our case a left hemi-diaphragmatic defect with normally and therefore symptoms are rare.18 The most herniation of stomach and coils of intestine into the frequently displaced organ is the stomach followed by thorax, compression of the left lung and mild the colon, spleen, small intestine and ureter.18,19,20 mediastinal shifting was observed. The principal management of Bochdalek hernias include reducing The overall prevalence of asymptomatic BH in adults the abdominal organs and repairing the defect. The is 6%. From all patients with a congenital BH only 5% surgical approach for this pathology depends on the 21 will be diagnosed in childhood or adulthood . In 1959 presence of visceral complications. In an elective Kirkland published the first review of 34 cases of adult setting most authors recommend the thoracic 1 BH . Adult BHs can present in two ways. They can give approach; on the other hand, when there are septic rise to vague, mainly gastrointestinal (abdominal pain, complications, the abdominal approach is preferred. nausea and vomiting, constipation) or respiratory The current trend is to use minimal invasive surgical (chest pain, dyspnoea, wheezing) symptoms, followed techniques such as laparoscopy, and specially by severe attacks and episodes of incarceration with thoracoscopy, which has been satisfactorily performed serious consequences. Characteristically, these in adults.9,27-29 symptoms can be intermittent, as herniated viscera can spontaneously reduce causing symptom regression. Very few cases of delayed presentation of CDH in Others will present with serious complications asymptomatic adults are described in the literature. We associated with strangulation of herniated viscera, report a case of asymptomatic adult patient who was especially when the diagnosis has been missed or referred to us for the evaluation of persistent left lung treatment delayed. There have been reports of BH opacity on chest X-ray. Computed tomography of the presenting with sudden death from intrathoracic lung confirmed the diagnosis of diaphragmatic
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