Interesting Case Presentation

Group 4

Personal Data

• P.B.• 71 year old/female• Single• DOA: December 13, 2009

• CC: left lumbar pain

History of Present Illness• Chest Xray: soft tissue mass superimposed by

the left cardiac above the medial aspect of the left hemidiaphragm

• CT Scan: high position kidney herniating through the foramen of Bochdalek

20 years

2 years• (+) left sided chest heaviness, aggravated

when lying supine• No consult

History of Present Illness• (+) left lumbar pain• Consult

– UTZ: questionable ectopic kidney– CT Scan: Bochdalek’s hernia (left) minimal

pneumonitis inferior lingula, atheromatous aorta, thoracic spondylosis, diffuse osteoporosis, nephrolithiasis, left

1 year

3 months• Persistence of symptoms• Consult

• CT Urogram: posterior left diaphragmatic hernia with intrathoracic left renal and colon, herniating, malrotated left kidney

Review of Systems• No fever, weight loss, anorexia• No rash, pruritus• No headaches, dizziness• No visual disturbance, no colds and cough• No diarrhea, no constipation• No dysuria, hematuria• No polydipsia, polyphagia, polyuria, no heat and

cold intolerance• No easy bruisability, no bleeding

Past Medical / Surgical History

• (+) Hypertension – maintained on Amlodipine 5mg/tab 1 tab OD

• No asthma, allergy• No DM• No previous surgeries or confinements• No previous blood transfusion

Family History

• (+) HPN – mother• (+) lung disease – mother• (+) stroke – brother• (+) heart disease – brother• (+) goiter – mother• (-) DM, asthma, allergy, CA

Personal History

• Non smoker• Non alcoholic drinker• Denies illicit drug use

OB and Menstrual History

• M : 12 years old• I : 28 – 30 days, regular• D : 3 days• A : 2 ppd/moderately soaked• S : (+) dysmenorrhea• Menopause at 48 years old

Physical Examination

• Conscious, coherent, ambulatory, not in cardiorespiratory distress

• BP 130/70 PR 92, regular RR 21, regular T 36.5

• Warm moist skin, no active dermatoses• Pink palpebral conjunctivae, anicteric sclerae,

no palpable lymphadenopathy

Physical Examination

• Symmetrical chest expansion, no retractions, decreased tactile and vocal fremiti on left lower lung field, clear breath sounds

• Adynamic precordium, AB 5th LICS MCL, no murmurs

• Flabby abdomen, NABS, soft, no mass, no tenderness

• Pulses full and equal, no cyanosis, no edema

Salient Features

• 71 y/o, Female• Left lumbar pain• Chest heaviness• No dyspnea• No nausea, vomiting• No abdominal pain,

distention, tenderness

• Bochdalek hernia– CT Scan– Urogram

• decreased tactile and vocal fremiti on left lower lung field

• No mediastinal deviation

Differential diagnosis

• Other congenital diaphragmatic hernias (Morgani’s)• Traumatic diaphragmatic hernia• Eventration

Morgagni hernias

• less common CDH

• 5-10% of CDH cases

• occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side

Eventration of the diaphragm

• anatomical or functional deficiency of part of the diaphragm, allowing abdominal contents to herniate into the chest

• more commonly right sided, and affects the anterior portion of the hemidiaphragm

Traumatic diaphragmatic hernia

• Blunt and penetrating traumas cause most acquired diaphragmatic hernias

• Left-sided rupture is more common than right-sided rupture, owing to hepatic protection and increased strength of the right hemidiaphragm

Bochdalek hernias of the diaphragm

• make up the majority of cases of CDH

• posterolateral defects of the diaphragm

• results in either failure in the development of the pleuroperitoneal folds or improper or absent migration of the diaphragmatic musculature

Assessment

• Bochdalek hernia

Plans

• CBC, Na, K• 12 L ECG• Chest X-ray• Exploratory laparotomy with possible

thoracotomy

Chest X-ray

Chest Xray (12/13/09) • Both lungs are clear• Heart is not enlarged• Pulmonary vascularity is within normal limits• Left hemidiaphragm is markedly elevated

• Gas-filled intestines are within the peritoneal cavity• There is no definite evidence of Bochdalek hernia

• Left sulcus and posterior gutter are intact

• There are moderate hypertrophic changes in the thoracic spine

• Impression: ELEVATED LEFT HEMIDIAPHRAGM, SUGGESTIVE OF EVANTRATION

Spirometry

• Based on FEV1/FVC ratio, there is no obstructive ventilatory defect.

• Flow volume loope is scooped out and the FEF 25-75 is low. Suggesting an early obstructive ventilatory defect.

• Based on the 3% change in FEV1, there is poor response to bronchodilator. There seems to be no associated restrictive ventilatory defect based on normal FVC.

• For verification we suggest a lung volume study.

Blood Chemistry

Na 137

K 3.8

TP 7.1 (N 6-7.8)

Albumin 4.1 (N 4-5.5)

Globulin 3.0 (N 1.5-3.4)

A/G Ratio 1.4

CBCHgb 117

Hct 0.35Platelet 288

WBC 9.40

Neutro 0.69

Seg 0.69Lymph 0.26Eo 0.05

Coagulation Assay

• PT 10.9s (10.3 -14.1)– NC 12.8– PT ratio 0.9– INR 0.9

• APTT 29.8 (27.0-45.4)– NC 36.1 s

Urinalysis

• Yellow• Clear• pH 6.0• SG 1.020• Alb neg• Sugar neg• RBC 0-2/hpf• Bac few

ECG

• Sinus arrythmia

OR Done

• Exploratory laparatomy with primary repair of Bochdalek hernia

Bochdalek Hernia

Primary Repair

OR Findings

• On opening, the spleen and left colon were mobilized, diaphragmatic hernia was appreciated at the posterior portion of the left hemidiaphragm. The left kidney and splenic flexure were seen herniated through the defect. All the other abdominal organs were grossly normal.

Final Diagnosis

• Bochdalek Hernia s/p primary repair of Bochdalek hernia

Discussion

Introduction

• It was first described in 1848 by Bochdalek

Embryology

• Failure of the pleuroperitoneal canal to close at eight weeks

gestation

Embryology

• Eighty percent occur on the left side• Bilateral, occasionally• The defect ranges from a small circular hole (Bochdalek hernia) to total absence of hemidiaphragm

Embryology

• Alter growth of the ipsilateral lung• Sometimes, it would alter the contralateral lung (when mediastinum shift to contralateral)

Pathogenesis

• Defective migration of muscle and nerve cell precursors to the diaphragm during formation

• Diaphragm develops anteriorly as a septum between the heart and liver and then grows posteriorly

• Final closure is at the left Bochdalek foramen between 8 and 10 weeks GA

• Bowel migrates from yolk sac to abdominal cavity at 10 weeks

• If bowel arrive before the foramen closes then hernia can occur

Epidemiology

• Frequency in neonates: 1/7000• Male/female ratio: 3:2 to 2:1• Very uncommon in adult• 1992 – 100 cases reported in the literature

– Growing use of abdominal CT, increase detection in asymptomatic individuals

Luis Bujanda etc 2001~

• incidence of 0.17% based on 13,138 abdominal CT reports we reviewed.

• The mean age of the patients was 66.6 years. None of the patients were symptomatic.– Sixty-eight percent of the hernias were on the

right side of the body, 18% were on the– left side, and 14% were bilateral. Seventy-three

percent contained only fat or omentum,Prevalence of Incidental Bochdalek’s Hernia in a Large Adult Population

Mullens Et alPresented at the annual meeting of the Radiological

Society of North America, Chicago 2000

Bochdalek Hernia

• Adult Bochdalek hernias are more frequently in women patients (77%) than in men.

• Contents– 73% intraabdominal fat or omentum only– 27% had solid or enteric organ involvement

• stomach, liver, spleen (33%), pancreas, or kidney (50%)

Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental

Bochdalek’s hernia in a large adult population. AJR 2001;177: 363–6.

• In adults, most Bochdalek’s hernias are likely to be asymptomatic.

Hines GL, Romero C. Congenital diaphragmatic hernia in the adult. Int Surg 1983;68:349–351

• Previously unrecognized Bochdalek hernia in the adult patient is often diagnosed incidentally to other problems.

• The most common presentation is left-sided abdominal and chest pain, associated with difficult breathing and intestitial obstruction.

Thomas S, Kapur B. Adult Bochdalek hernia: clinical features, management and

results of treatment. Jap J Surg 1991; 21(1): 114–119.• Sometimes, only gastrointestinal symptoms,

caused mainly by obstruction of abdominal viscera.

Steenhuis L.H., R.T.O. Tjon A Tham, F.W.J.M. Smeenk. Bochdalek hernia: a rare cause of pleural empyema. Eur Respir J, 1994, 7, 204–206

Image examination

• Chest x-ray (NG tube insertion)• Plain abdomen• Barium enema study• Upper GI barium study• Abdominal CT

– Most accurate, – Can also detect associated anomalies

• Abdominal MRIShin MS, Mulligan SA, Baxley WA, Ho KJ. Bochdalek hernia

of diaphragm in the adult. Diagnosis by computed tomography.Chest 1987;92:1098-1101

• Small, asymptomatic Bochdalek hernia does not require surgical intervention.

Shin M S, S A Mulligan, W A Baxley and K J Ho.

Diagnosis by computed tomography. Bochdalek hernia of diaphragm in the adult. Chest 1987;92;1098-1101

• Once diagnosed, the reduction of abdominal viscera in the abdominal cavity is mandatory due to the risk of life threatening complications.

Kocakusak A, Arikan S, Senturk O, Yucel AF. Bochdalek’s hernia in an adult with colon necrosis. Hernia 2005;9:284–7.

• As soon as the diagnosis is made, operative repair should be carried out - even if there are no symptoms - because of the severe complications that large hernias can give, such as strangulation of hernial contents.

L.H. Steenhuis, R.T.O. Tjon A Tham, F.W.J.M. Smeenk. Bochdalek hernia: a rare cause of pleural empyema. Eur Respir J, 1994, 7, 204–206

Management

• Aim: Reducing the viscera and sealing the diaphragmatic defect

• Surgical repair is the most logical management– Laparotomy– Thoracotomy– Laparoscopy– Thoracoscopy– Or combinations

Surgical Approach• Transthoracic

– enables a direct observation of the herniated viscera and allows an easier lysis of the adhesions with the hilum located in the posterolateral region of the diaphragm

• Transperitoneal– allows the surgeon to confirm the position of the viscera

after “pull-back” and to repair any malrotation if present.

Masafumi Yamaguchi MD, et al. Thoracoscopic Treatment of Bochdalek Hernia in the Adult: Report of a Case.

Ann Thorac Cardiovasc Surg Vol. 8, No. 2 (2002)

Complication

• Volvulus formation• Incarceration, strangulation• Hemorrhage• Perforation of a hollow viscus

Prognosis

• Poor when it is manifested at birth• Good in adult (<3% mortality)• Poor in adult when complication appear (organ ischemic change, hemorrhage,…)

Thank you!