Traumatic diaphragmatic hernia is an uncommon but important problem in the patient with multiple injuries. Since diaphragmatic injuries are difficult to diagnose, those that are missed may present with latent symptoms of bowel obstruction and strangulation. The same may occur in the patients with stab wounds to the lower chest. Traumatic diaphragmatic hernia should be suspected on the basis of an abnormal chest radiograph in the trauma victim with multiple injuries.
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Posterolateral Bochdalek diaphragmatic hernia in adults. School of Medicine. University of Granada. Hospital Universitario San Cecilio. Facultad de Medicina.
Universidad de Granada. Granada, Spain. Bochdalek hernias BHs are produced in the posterolateral area of the diaphragm. They are generally congenital, appearing in childhood, but are also detected in asymptomatic adult patients seeking medical attention for other reasons.
Computed tomography CT or magnetic resonance imaging MRI is used for the correct diagnosis of the hernia type and for its localization, facilitating its management and the choice of treatment.
We describe three cases of Bochdalek hernia, two on the right side and one bilateral, which was larger on the right than left side. All of these hernias contained only omental fat. In one patient, the right kidney was adjacent to the diaphragmatic defect but remained within the abdomen. The patients showed no symptoms and were not surgically treated.
Examination by multi-slice CT with the possibility of coronal and sagittal reconstruction should be considered the standard method for diagnosing this entity. MRI in T1 is highly valuable to evaluate fat-containing chest lesions. The incidental finding of BH in asymptomatic adults is increasing, thanks to the wider application of new imaging techniques.
Key words: Bochdalek hernia. Congenital diaphragmatic hernia. Computed tomography. Magnetic resonance. Palabras clave: Hernia de Bochdalek. The presence of a weakened space or defect in the diaphragmatic muscle can allow some contents of the abdomen to enter into the thoracic cavity, forming a herniation.
Diaphragmatic hernias DHs are most frequently produced in the esophageal hiatal hernia and paraesophageal hiatus paraesophageal hernia and posterolateral -Bochdalek hernia BH -, and anteromedial -Morgagni hernia MH - regions of the diaphragm The etiology can be congenital, due to alterations in diaphragm development, or acquired as the result of surgery, trauma, or infection. The causes of late-presenting hernias i. It has also been related to long-term complications of continuous ambulatory peritoneal dialysis 8.
Most congenital diaphragmatic hernias CDHs appear in the neonatal period with respiratory distress and can be life-threatening 6,9, However, cases have been reported outside this age group, usually in adults with non-specific or no symptoms 5, In Spain, the frequency 14 of a hernia or diaphragmatic agenesis diagnosis in the first three days of life was reported to be 2.
The estimated prevalence of BH ranges from 0. There can sometimes be a small diaphragmatic defect without hernia. There have been no cases of lung hernia through a diaphragmatic opening Most published cases of MH and BH diagnosis and repair are in children, with only 5 per cent being reported in adults Although a diaphragmatic dysgenesis is widely considered to be the origin of CDH, only 10 per cent of CDH patients were found to have chromosomal anomalies BHs can affect both sides of the body, in the region where the lateral arcuate ligaments of the diaphragm curve, covering the quadratus lumborum muscles, and laterally fix on either side of the twelfth rib and medially to the transverse process of L1 9,10, An yr-old man was hospitalized for intense epigastric pain that did not respond to analgesic medication; he also reported persistent constipation with altered bowel habit.
He suffered from senile heart disease, aortic sclerosis and venous insufficiency in lower limbs. He had a history of chronic obstructive pulmonary disease COPD and a major atrial fibrillation treated with actocortin in the emergency area, which has not recurred.
He subsequently underwent surgery for bladder cancer grade I papillary transitional carcinoma involving the corium. Conventional posteroanterior chest X-ray Fig. Chest-abdominal computer tomography CT study revealed some paraseptal bullae with pulmonary emphysema, increased density of residual appearance in the apex of the right lung, interstitial pattern with bibasal predominance, cardiomegaly at the expense of both atria , mitral and aortic valve calcifications, small subcarinal lymph nodes, and possible right hilar lymph nodes.
There were also mild pleural thickenings with right predominance and chronic appearance. Additionally, there was a small right BH with fatty content of around 25 mm Figs. In the abdominal region, a small vesical diverticulum 12 mm was observed on the right lateral wall. A year-old male was hospitalized for epigastric pain and vomiting, which were interpreted as a biliary colic. However this diagnosis could not be confirmed by X-ray, which showed no findings of interest Figs.
Cholangio-MRI Fig. Three years earlier, he had been diagnosed with moderately differentiated rectal adenocarcinoma pT 3 pN 0 , which was treated with surgery, chemotherapy, and radiotherapy. Finally, chest-abdominal CT revealed small subpleural pulmonary nodules, a small hiatal hernia, and bilateral BH with fatty content Figs. In the abdominal region, there were small cysts in the renal parenchyma and a metal suture in the rectum from the previous surgery.
An year-old female with respiratory insufficiency was hospitalized for a respiratory infection. Posteroanterior Fig. The lateral X-ray showed dorsal kyphosis and wedge-shaped vertebrae.
Chest CT Figs. The scan also showed a sliding hiatal hernia and right BH with fatty content. The diaphragm is formed between week 4 and 12 of gestation by four embryologic elements: septum transversum, pleuroperitoneal membranes, mediastinal dorsal mesentery of the esophagus, and muscles of the body wall 10, It has been hypothesized that the liver usually obstructs herniation through a possible defect on the right side.
Furthermore, the right hemidiaphragm is completely formed before the left, because of the earlier closing of the right pleuroperitoneal canal when the intestine returns to the peritoneum from its rotation in the yolk sac 11 , hence per cent of all BHs, better described as posterior diaphragmatic defects 19 , are on the left side 6 , although Mullins et al.
They also found a 14 per cent possibility of bilaterality. We report three cases of BH, two on the right side and one bilateral in which the largest hernia is on the right side. The size of a BH is usually highly variable, from a few millimeters to occupying most of the thorax, and it is not necessarily related to the size of the diaphragmatic defect 5,11,20 ; 20 per cent of BHs are contained by a sac, and the remainder show direct communication between thorax and abdominal cavity BHs typically contain omental fat, which can be accompanied by the stomach, spleen, colon, and even the small intestine 10,11,16,20,22, The involvement of the liver, gallbladder, pancreas, kidney, or retroperitoneal fat is rare 5 , and there has been no report of a lung component in adult BH In all our cases, the content was omental fat alone.
However, in one of them, the right kidney was adjacent to the diaphragmatic defect but inside the abdomen Figs. In newborns, the protrusion of the liver inside the right hemithorax is typically due to a CDH. In these cases, the liver will cause a mass effect and displace the mediastinum towards the left. However, if the mediastinum is not displaced, other less common causes for intrathoracic liver should be considered, such as primary right pulmonary hypoplasia e. Most congenital BHs are associated with a respiratory insufficiency 21 that becomes evident during the first weeks of life, and they are among the most frequent causes of respiratory distress in neonates.
In adults, most BHs are usually asymptomatic 16 and their detection is incidental, as in our three patients. Symptoms, if any, are typically imprecise. Patients usually report chest pain or gastrointestinal symptoms 5,7, A case was reported of a yr-old woman in the second trimester of pregnancy with symptoms of retching, oliguria, and shortness of breath that were initially attributed to the pregnancy itself but finally proved to be caused by a left BH with acute gastric volvulus One of our patients was hospitalized for intense epigastric pain, but its relationship with the BH could not be demonstrated.
There have been rare reports of late presenting BH with gastric volvulus, spleen rupture, obstruction, and gastrointestinal perforation 23,25, Congenital BHs can be diagnosed by ultrasound, even in the prenatal period, as a displacement of the mediastinum and a mass in the thorax of the fetus 2.
Chest-abdominal X-rays of a neonate with BH and respiratory distress show a soft tissue mass in the thorax that reveals gas or hydro-air levels when the neonate swallows air. X-rays with radiopaque contrast may be useful before surgery to assess the herniated intestinal loops and their possible malrotation 10, Occasionally, a BH can appear as a lesion with soft tissue density in the posterior area of the pulmonary base in lateral chest X-rays 6,11 , which may be confused with a pulmonary lymph node adjacent to the diaphragm 27 or, as in one of our cases, with a posterior diaphragmatic lobulation Figs.
Using CT, however, a BH can be readily differentiated from a diaphragmatic eventration or lobulation "bosselation" by examining the continuity of the diaphragm muscle itself. In BH, the muscle always shows a break or defect, whereas it is always whole, though thinned, in the other two conditions In two of our patients, with known malignant disease, the predominant clinical indication for CT was to rule out metastatic disease, as reported by other authors 5.
Examination by multi-slice CT, with the possibility of coronal and sagittal reconstruction, should be considered the standard method to diagnose BH 5. Some authors recommended replacing conventional axial images with coronal reformatted images, because there are fewer images and less time is required for interpretation However, it has been verified that the lack of familiarity of observers with coronal visualization may contribute to detection errors and the missing of defects CT and MRI studies are highly valuable for the assessment of fat-containing thoracic lesions 6 , detecting, localizing, and identifying lesions and markedly reducing the time required for the differential diagnosis Figs.
CT or MRI diagnosis can be definitive. In BHs, sagittal and coronal reformatted images can reveal the diaphragmatic defects and hernia contents Figs. The treatment of incidental BH remains controversial 5. All DH types are assumed to have a congenital origin, but the clinical presentation, management, complications, and prognosis markedly differ between neonate and adult cases. The prognosis for late-presenting BH is usually more favorable 13,16 , as in the present patients, who have shown no clinical or imaging changes after a follow-up of up to six years.
Despite the generally symptom-free nature of incidental BH in adults, some authors recommend surgery, including hernia reduction and defect closure, arguing that the risk of tissue strangulation and even death warrants an aggressive approach 7. The diagnosis of BH as an incidental finding in adulthood appears to be increasingly frequent.
Given the growing prevalence of obesity in our society, there may be a connection between these phenomena, which would have public health implications 7. The incidental finding of BH in asymptomatic adults appears to be increasing, largely due to the application of new imaging techniques. The use of CT or MRI offers greater precision in the diagnosis, localization and characterization of the hernia, facilitating its management and the choice of treatment.
Diferencial diagnosis of fat-containing lesions with abdominal and pelvis CT. RadioGraphics ;
Congenital diaphragmatic hernia
Hight diaphragmatic hernia with hepatothorax - case report and literature review. At admission, he was with abdominal pain and respiratory distress. Submitted to image investigation, had the diagnosis done of a diaphragm herniation. Laparotomy revealed liver and adjacent viscera into the thorax and a diaphragm defect of 15 cm. The defect was closed without the use any mash.
Hernia diafragmática congénita
There are a variety of etiologies for acquired diaphragmatic hernias that usually occur in adulthood 1 :. Depending on the location and size of the defect retroperitoneal or intra-abdominal organs and tissues can prolapse into thoracic cavity due to the negative intra-thoracic pressure 1. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Updating… Please wait.