An Adult Bochdalek Hernia Presenting With Constipation and Shortness of Breath

Abstract

Turkish Abstract

Introduction

Bochdalek hernia is a congenital diaphragmatic hernia occuring  as a result of intrauterin fusion failure of  posterolateral diaphragmatic foramina.They can, however, be acquired in adulthood due to a ?re-opening? of the coronary ligaments ¹.  It majorly manifests in neonates and infants with respiratory symptoms and its adult form is very rare ,but by the presentation of computed tomography(CT), it has been detected more day by day as an incidental finding in adults,  who are  asymptomatic  or suffering complications ².  Here we present the multislice CT findings of an adult with vague symptoms.

Case Report

33 years old male referred to our hospital with a left sided pain and constipation for a couple of weeks. He described difficulty in bending his trunk and a degree of shortness of breath. His laboratory tests and abdominal exam showed no pecularity. After he was scanned with 64- MDCT(multidetector computed tomography) and with intravenous contrast material administration, we detected a posteriolateral defect in the diaphragma on the left side in his thoracal CT images . Abdominal visceral fat and a part of  splenic flexura  were herniated to the thorax through this diaphragmatic defect. He was recommended surgical treatment. (Figure 1, 2a, 2b)

Figure 1 Topogram of the patient

Figure 2A Sagittal view of the Bochdalek hernia. The defect is shown with white arrows.

Figure 2B The coronal view of the defect. Again it is shown with white arrows.

Discussion

Bochdalek hernia is a nonclosure of pleuroperitoneal ducts in intrauterin life and mostly  manifests in neonates and infants ^3,4 with the incidence of approximately 1 in 2200 to 12500 live births ⁵. The majority of adult Bochdalek hernias  are  asymptomatic and  found  incidentally, but  isymptomatic Bochdalek hernias may lead to incarcerated bowel,  intraabdominal organ dysfunction, or severe pulmonary disease ^1,6,7.

The symptoms present themselves as gastrointestinal complaints such as changes in bowel habits,nausea and cramp like abdominal pain which result from  complications  like the obstruction of the herniated organ. The pulmonary  complaints such as  shortness of breath, recurring chest infections and other pulmonary sequels  are less encountered ⁸ . Bochdalek hernias may contain one or more of the following: stomach, spleen, colon, omentum, and small bowel. Also liver, gallbladder, pancreas, kidney, or retroperitoneal fat has infrequently been described  as hernia contents ³.  Symptomatic adult  Bochdalek hernias are usually left-sided due to two possible mechanisms. The compression of the caudate lob of the liver on the  right pleuroperitoneal canal and thus preventing the right sided herniation is the first possible  mechanism^9,10. Whereas the right hemidiaphragm  fully forming  embriologically before the left ,may be contributing in the prevention of the right sided herniation ^9,3 .

Diagnosis can be made by utilizing imaging tools. Plain film can give an idea of the hernia with the colon gas seen over the diaphragma ⁸, but plain film has low sensitivity and it can lead to misdiagnosis and confusion with other  thoracal pathologies  like left middle lobe collapse, air space consolidation, pericardial fat pad, sequestration of the lung, mediastinal lipoma, or anterior mediastinal mass ^6,11 . CT  is highly dependable for making  the accurate  diagnosis by  directly visualising  the  exact localization of the diaphragmatic defect  , and the contents of the hernia.The accurate diagnosis is the first step to  proper management conduction and  avoidance  of  unneceessary comprehensive surgical interventions . Like making the accurate diagnosis,the  timely treatment is  also crucial for the patients. Severe complications are prevented if this imaging is performed without delay.

 The treatment of Bochdalek hernia is operative and according to the severity of the symptoms and the accuracy of the procedure, patients generally do not have any recurrence and remain asymptomatic ² .

Conclusion

With the various and vague clinical symptoms , Bochdalek hernia is difficult to diagnose. CT is superb in the diagnosis of diaphragmatic hernias with the capability of multiplanar reconstruction. It can also detect any potential co- morbidities and  prevents misdiagnosis which are possible without the utilization of CT.

References

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