The combination of Chilaiditi syndrome and Bochdalek hernia in an adult: successful management with a robot assisted approach A 57-year-old female presented with 1 week of sudden onset generalized abdominal pain, obstructive symptoms and progressive dyspnea on exertion. Examination revealed abdominal distension with guarding and tenderness in the right upper quadrant. Vital signs and bloods were normal.Computed tomography (CT) with oral and intravenous contrast of the abdomen and pelvis demonstrated herniation of the right liver and large bowel into the right anterior thoracic cavity above the diaphragm consistent with a Bochdalek Hernia (BH) (Fig. 1). The hernial neck measured 62 mm. There was interposition of sigmoid colon above the liver consistent with Chilaiditi syndrome (ChS) with associated stranding and free fluid suggestive of incarceration. No pneumoperitoneum or pneumatosis was visualized.Given the acute signs and incarceration of the bowel, the decision was made for surgical repair. A multidisciplinary approach with colorectal and cardiothoracic surgery using a robotic platform Fig. 1. Coronal and axial CT image demonstrating intrathoracic displacement of the liver as well as interposition of the above the liver with associated stranding. (a) The arrow shows colon interposition above the liver, the star shows faecal loading of the caecum. (b) The arrow demonstrates stranding of the colon. (c) The diaphragm is shown in red and herniation of the liver and colon through the diaphragmatic defect can be seen. (d) The hernia neck is measured 62 mm (white arrow). (e) Intrathoracic displacement of liver and colon is visualized and stranding of the colon and associated free fluid (star) suggests incarceration.
We report the case of a healthy 35-year-old male with two rare pathologies: pneumopericardium and oesophago-pericardial fistula (OPF) secondary to tuberculosis. Purulent pericarditis and cardiac tamponade are known complications with potential for significant morbidity and mortality. Unfortunately, the symptoms of OPF are non-specific often delaying diagnosis. There is no gold standard for treatment or determinant of when nonsurgical versus surgical approach should be considered. Anti-tuberculous therapy alone is often adequate however an oesophageal stent was utilized in this case to rapidly gain control of the fistula and prevent ongoing contamination from mediastinitis.
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