---

BOCHDALEK HERNIA OF DIAPHRAGM IN AN ADULT

Ratna S Parikh, V Upasane, R M Joshi, SK Mathur, J M Joshi
Dept. of GE Surgical Services and Chest Medicine, TNMC and BYL Nair Hospital, Mumbai.

---

We report a case of Bochdalek Hernia of diaphragm in an adult with acute onset of chest pain and breathlessness. The presence of bowel sounds in the left hemithorax and findings of a herniated stomach into the left hemithorax through a ruptured left diaphragm on chest roentgenogram were diagnostic. A CT scan examination suggested a large sized hernia and established the contents of the hernia. Nasogastric tube aspiration immediately relieved symptoms and an early surgery was curative.

Diaphragmatic hernia through the foramen of Bochdalek usually presents in the neonatal period because of its large size. It occurs in one of every 2500 live births. [1] Among adults, with the advent of computed tomography (CT), the small, asymptomatic Bochdalek hernia containing fat has been detected with much greater frequency. [1,2] However, a large sized, Bochdalek hernia presenting in an adult with acute onset of breathlessness is uncommon. [2]

CASE REPORT

A 25 year old male presented with acute onset progressive pain in the left hemithorax associated with breathlessness of 8 hours duration. On examination he had tachypnoea, with stable haemodynamic parameters. Abdominal examination was essentially normal. Chest examination revealed shift of the trachea to the right, reduced breath sounds and a tympanic note in the left hemithorax.

INVESTIGATIONS

Haematological investigations were within normal limits. Plain skiagram of the chest showed a herniation of the stomach into the left hemithorax and shift of the mediastinum to the right (Fig. 1). A left lateral decubitus film showed a large air fluid level in the left hemithorax. CT scan of the thorax showed a large paravertebral round mass containing stomach, spleen, splenic flexure of the colon, bowel loops situated in the posterolateral aspect of the left hemithorax, discontinuity of the soft tissue line of the diaphragm with continuity of subdiaphragmatic and supradiaphragmatic densities through the defect suggestive of Bochdalek hernia (Fig. 2).

Fig. 1 : Chest skiagram showing herniation of the stomach in to the left hemithorax.	Fig. 2 : CT scan showing hernial contents.

The stomach was decompressed using a nasogastric tube, which drained 2 litres of gastric contents. Gastric aspiration resulted in reduction in pain and breathlessness. Patient was then explored through a midline abdominal incision. At exploration the stomach, spleen, left colon and small bowel were seen to be herniated through a smooth defect of 12 cm x 3 cm in the posterolateral aspect of the diaphragm. No hernial sac could be identified. The diaphragmatic defect was sutured in 2 layers with interrupted non-absorbable suture. An intercostal drain was kept for 72 hours. Postoperative recovery was uneventful and a skiagram of the chest done 24 hours later showed full expansion of the left lung.

DISCUSSION

Diaphragmatic hernias may be congenital or acquired secondary to thoraco-abdominal trauma like traffic accidents. In both types, hernia is most often through the left hemidiaphragm and without a sac. [2] Absence of any past history of trauma, no evidence of adhesions and large nature of hernia in our case suggest it to be congenital in origin.

Hernia through the pleuroperitoneal hiatus - foramen of Bochdalek was first described in 1848 and results from the failure of fusion of the lateral (costal) with the posterior (crural) components of the diaphragm.[1] In our case CT scan and operative findings confirm the hernia through the pleuroperitoneal hiatus.

The prevalence of Bochdalek hernia in adults has been disputed. [3-5] Most cases are diagnosed in the neonatal period, clinical features been related to respiratory system. Acute onset of symptoms in congenital Bochdalek hernia may be due to strangulation [6] or massive distension of hernial contents. In our case large gastric aspirate and prompt relief of symptoms suggest that gastric distension within the thorax was the most likely cause of symptoms. Presence of bowel sounds on chest auscultation could be clue to the correct diagnosis. [5] Plain skiagram of the chest is adequate to diagnose large herniations as seen in our case, but small ones are not visible. [2] Also a previous normal chest roentgenogram does not rule out the presence of a hernia. CT scan is diagnostic for small hernias and helps to identify the contents of the hernia. [2] Once identified these hernias should be repaired to prevent life threatening complications.

REFERENCES

1. Gale ME. Bochdalek hernia : Prevalence and CT characteristics. Radiology 1985; 156 : 449-52.
2. Shin MS, Mulligan SA, Baxley WA, Ho KJ. Bochdalek hernia of diaphragm in the adult. Diagnosis by computed tomography. Medical Imaging. Chest 1987; 92 : 1098-101.
3. Ramprasad G, Vidyasagar B. Bochdalek’s hernia simulating pleural effusion. Lung India 1989; 7 (2) : 95-6.
4. Steenhuis LH, Tjon A Tham, Smeenk FJ. Bochdalek hernia a rare cause of pleural empyema. Eur Respir J 1984; 7 : 204-6.
5. Sundaram P, Kamble RT, Joshi R, Hardikar J, Joshi JM. Bochdalek hernia presentation in adult. J Assoc Physicians of India 1996; 44 : 214-5.
6. Sinha M, Gibbon P, Kennedy SG, Matthews HR. Colopleural fistula due to Bochdalek hernia in an adult. Thorax 1989; 44 : 762-3.

To Section TOC