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Ann Thorac Surg 2002;73:1288-1289
© 2002 The Society of Thoracic Surgeons

Case report

Symptomatic Bochdalek hernia in an octogenarian

Paul Perch, MDa, Ward V. Houck, MDa, Abe DeAnda, Jr, MD*a

a Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Virginia, Richmond, Virginia, USA

Accepted for publication July 30, 2001.

* Address reprint requests to Dr DeAnda, West Hospital, 1200 E Broad St, 7th Floor, South Wing, Room 7305, Richmond, VA 23298 USA
e-mail: adeanda{at}nsc1.nsc.vcu.edu


   Abstract
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 Abstract
Introduction
 Comment
 References
 
We present a case of an 88-year-old man who presented with chest pain and shortness of breath. Chest radiography suggested the presence of a ruptured diaphragm, and on exploration a left Bochdalek defect with herniation of stomach and small bowel into the left pleural cavity was found. This was repaired and the patient eventually was discharged to a nursing facility. We believe this represents the oldest patient presentation of a symptomatic Bochdalek hernia.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Bochdalek hernia is a posterolateral congenital defect of the diaphragm usually presenting in the pediatric population with acute respiratory insufficiency. Large defects are associated with lung hypoplasia on the effected side with early respiratory insufficiency following birth. Smaller defects usually are not associated with abnormal lung development and may be completely asymptomatic until acute herniation of abdominal contents into the pleural space causes subsequent respiratory embarrassment. Also, the potential for strangulation of the herniated organs makes this condition a surgical emergency. Adult presentation, while rare, is a well-described clinical entity. The following case presentation illustrates not only the typical findings, but also the danger associated with a delay in diagnosis. We believe that this represents the oldest patient presentation of a symptomatic Bochdalek hernia.

An 88-year-old man was admitted to an outside hospital with a 2-day history of chest pain and shortness of breath. His chest pain worsened with deep breathing, and he reported a productive cough of white-colored sputum. He was without fever, chills, nausea, or vomiting. His past medical history was remarkable for asthma as well as tobacco and alcohol abuse. There was no history of trauma. On his initial physical exam, he was in significant respiratory distress, tachypnic at 40 per minute with diffuse rhonchi and expiratory wheezing. The abdominal exam was unremarkable.

Preliminary laboratory values included hemoglobin of 13 g/dL and a white blood cell count of 19,400 per cc (with 20% bands). The serum electrolytes revealed an anion gap of 30 meq/L with arterial blood gas remarkable for pH 7.17, pCO2 19 mmHg, pO2 69 mmHg. There was no evidence of myocardial ischemia.

A chest roentgenogram revealed marked elevation of the left hemidiaphragm with a concentric stripe of air immediately beneath it, and the splenic flexure and abdominal contents in the region of the left hemithorax. Because of his respiratory status, the patient was intubated and a nasogastric tube placed. A repeat chest film to confirm tube placement showed significant rightward mediastinal shift, the presence of gas bubbles, and the tip of the nasogastric tube in the left hemithorax (Fig 1). An unenhanced computed tomography of the chest, abdomen, and pelvis with oral contrast was then obtained. This revealed multiple small and large bowel loops in the left chest with a resultant right mediastinal shift and possible gastric volvulus (Fig 2).



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  		Fig 1. Chest radiograph following intubation and nasogastric tube placement. Note shift in mediastinal contents and bowel in left chest.

 


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  		Fig 2. Chest computed tomographic scan (representative frame) demonstrating contrast-filled stomach in left chest with no evidence of extravasation of contrast.

 
The patient was then transferred to our facility 57 hours after his initial presentation, and underwent a left thoracotomy for a presumed ruptured diaphragm. A small, incarcerated posterolateral left diaphragmatic hernia was found, measuring 3 cm x 3 cm. Several chronic adhesions to the left lung were lysed. The proximal stomach and several loops of small bowel were reduced back into the abdominal cavity and a Gore-Tex patch (ePTFE Cardiovascular patch, Impra Inc, Tempe, AZ) was used to close the diaphragmatic defect. After closure of the chest, the patient was repositioned supine and an upper midline exploratory laparotomy was performed. The stomach, small bowel, and colon were without perforation and appeared viable. A feeding jejunostomy tube was placed, and the patient was taken to the intensive care unit for recovery. The patient was extubated and improved until postoperative day 8 when he developed increasing abdominal distension. An enhanced abdominal computed tomography without oral contrast was obtained and revealed a large amount of free intraperitoneal air. A reexploration laparotomy revealed multiple areas of necrosis and perforation of the proximal stomach in the region of the cardiac and lesser curvature. A proximal gastrectomy with esophagogastrostomy was performed. The patient eventually improved and was discharged to a nursing care facility.


   Comment
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 Abstract
 Introduction
 Comment
References
 
In 1848, Bochdalek described a congenital diaphragmatic hernia that would soon thereafter bear his name. The hallmark of the Bochdalek hernia is its posterolateral position in the diaphragm that results from failure of the pleuroperitoneal folds to fully mature.

Bochdalek hernia presentation in adulthood is rare with little more than 100 cases reported in the literature [1]. Delayed presentations are more frequent in males by 3:1. A left-sided diaphragmatic defect is present 70% to 90% of the time, thought to arise in part from a differential in the timing of pleuroperitoneal fold fusion between the right and left sides and in part by a protective effect exerted by the liver on the right side. Rarely, hernias present bilaterally or only on the right side [2]. A peritoneal hernia sac is not present in over 85% and also appears dependent on the timing of pleuroperitoneal fold fusion.

Adulthood clinical presentation can be complex with symptomatology generally referable to the aerodigestive tract. Gastrointestinal tract symptoms can include intermittent abdominal pain, vomiting, and dysphagia. Respiratory symptoms usually include chest pain and dyspnea. Delayed and missed diagnosis, as in this case, is a common feature to many presentations and can result in highly morbid and sometimes lethal outcomes [3]. The contents of the Bochdalek hernia may vary depending on the side of the defect. The large and small bowel is most commonly involved [3]. The stomach and omentum are also frequently seen. Herniated contents have also included the liver, gallbladder, spleen, kidney, adrenal gland, and pancreas [4].

A chest roentgenogram demonstrating gas and fluid-filled viscera above the diaphragm can support the diagnosis of Bochdalek hernia. Other more subtle findings include blunting of the costophrenic angle, presence of a posterior mediastinal mass, and small pleural effusion [4]. Computed tomography can also be diagnostic. Typical findings are abutment of fat or soft tissue along the upper surface of the diaphragm, characteristic posterolateral location on the hemidiaphragm, diaphragmatic discontinuity adjacent to the mass, and density continuity above and below the diaphragm through the defect [4]. Intestinal series with gastrograffin or barium have also been used to confirm the diagnosis [4].

Effective treatment involves reducing abdominal contents and repairing the diaphragmatic defect. Transthoracic repair is the usual choice for right-sided Bochdalek hernias, while controversy exists regarding the optimal surgical approach for left-sided hernias. Some support laparotomy and believe this approach is most advantageous for malrotation recognition and treatment [5]. Thoracotomy advocates cite an improved ability to divide chronically formed adhesions between abdominal viscera and thoracic structures [3]. However, both approaches may prove equally suitable. More recently, both laparoscopic and thoracoscopic techniques have been successfully utilized in repair of these rare hernias [6].

In summary, Bochdalek-type congenital diaphragmatic hernia can present in the adult or even geriatric population. Outcome of adult patients having Bochdalek hernia depends on the type of clinical presentation. The mortality rate for elective surgery has been reported at less than 3% [5]. However, mortality can be as high as 32% when patients present acutely, when diagnosis is delayed (as in this case) or complications develop [5]. A high index of suspicion can result in early diagnosis and prompt intervention with reduced morbidity and mortality.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Bujanda L., Larrucea I., Ramos F., et al. Bochdalek’s hernia in adults. J Clin Gastroenterol 2001;32:155-157.[Medline]
  2. Sener R.N., Tugran C., Yorulmaz I., Dagdeviren A., Orguc S. Bilateral large Bochdalek hernias in an adult. CT demonstration. Clin Imaging 1995;19:40-42.[Medline]
  3. Sugg W.L., Roper C.L., Carlsson E. Incarcerated Bochdalek hernias in the adult. Ann Surg 1964;160:847-851.[Medline]
  4. Wilbur A.C., Gorodetsky A., Hibblen J.F. Imaging findings of adult Bochdalek hernias. Clin Imaging 1994;18:224-229.[Medline]
  5. Fingerhut A., Baillet P., Oberlin P.H., Ronat R. More on congenital diaphragmatic hernia in the adult. Int Surg 1984;69:182-183.[Medline]
  6. Frantzides C.T., Carlson M.A., Pappas C., Gatsoulis N. Laparoscopic repair of a congenital diaphragmatic hernia in an adult. J Laparoendosc Adv Surg Tech 2000;10:287-290.



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This Article
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Right arrow Diaphragm

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