Chest X-ray findings in late-onset congenital diaphragmatic hernia, a rare emergency easily misdiagnosed as hydropneumothorax: a case report

Abstract

IntroductionLate-onset congenital diaphragmatic hernia is a rare anomaly with misleading symptoms and signs.Case presentationWe describe the case of a 7-year-old Middle Eastern girl who presented with acute nonspecific abdominal symptoms and respiratory distress of 2 days’ duration after sustaining a blunt trauma on her left chest wall on a background of chronic ill-defined left chest pain of 2 weeks’ duration. Her initial chest radiograph showed an air-fluid level, which was thought to be a hydropneumothorax, so a chest tube was inserted and was shown to be positioned between the chest wall and the air collection; therefore, a nasogastric tube was inserted and it was positioned in the left chest cavity so the diagnosis of late-onset congenital diaphragmatic hernia was made. On retrospective analysis of the first abdominal X-ray, it showed a subtle lucent area that was triangular in shape and continued with the chest cavity, which indicates a sign of diaphragmatic hernia. In addition, the next unusual point was the nonvisualization of the diaphragm, which should be reported in any abdominal X-ray. An exploratory laparotomy was performed on our patient using a left-sided subcostal incision; the operative findings revealed a very small posterior rim of the diaphragm and a hypoplastic left lung. Her stomach, spleen, and left colon with the omentum were in the left side of her chest. She made an uneventful recovery postoperatively and was discharged after 1 week.ConclusionsGastric and intestinal gas shadow distribution provides an important marker in the diagnosis of late-onset congenital diaphragmatic hernia and should be sought for in every case of suspected congenital diaphragmatic hernia in addition to noting the position of the nasogastric tube in the chest cavity.

A Sudden Infant Death Due to Congenital Diaphragmatic Hernia

“…The aforementioned decedent falls into this category, providing a prime example of hidden mortality. A number of similar cases of otherwise apparently healthy patients, ranging in age at presentation from a few months to years and even decades, with abrupt symptom onset related to sudden herniation of abdominal viscera through the defect and into the thoracic cavity, have been reported (17)(18)(19)(20). Most patients with late-presenting CDH report upper quadrant pain, dyspnea, and vomiting, which occur either in one severe episode leading to medical investigation and diagnosis, or intermittently if herniation occurs and subsequently resolves without medical intervention (17)(18)(19)(20).…”

Tension gastrothorax in late-onset congenital diaphragmatic hernia, a rare but life-threatening condition

“…[ 5 ] When the diaphragmatic hernia is small, it is protected by the liver on the right, and the spleen on the left, so often there are no symptoms for several months to years of life and patients often have normal chest x-ray. [ 5 – 7 ] Late-onset CDH is less common, and can present with various symptoms, such as cough, dyspnea, chest pain, frequent respiratory infections, abdominal pain, diarrhea, and vomiting. In severe cases, patients can present with serious respiratory failure or cardiopulmonary failure.…”

“…Nevertheless, tension gastrothorax is often mistaken for tension pneumothorax or pleural effusion, leading to inappropriate thoracostomy. [ 3 – 5 ] This leads to delayed management, and inappropriate insertion of the chest tube can cause gastric perforation that can cause gastric contents leakage to the thoracic cavity. [ 3 , 6 , 7 ] Hence it is important that the chest x-rays should be carefully observed, and if the diagnosis is unclear with chest x-ray alone, CT scan is recommended for accurate diagnosis and prevention of inappropriate invasive procedures, such as thoracostomy.…”

“…Laparotomy approach is an often preferred surgical method [ 2 , 3 , 5 – 7 ] as it allows rapid reduction of the herniated organs, examination of the intraabdominal organs, and easier repair of the diaphragmatic hernia. [ 2 ]…”

Right sided bochdalek diaphragmatic hernia appeared as a life threatening event in an infant: a case report

“…The failure of closure of this foramen causes a persistent diaphragmatic defect, allowing abdominal viscera to be trapped in the thorax [ 1 , 6 ]. The absence of prenatal diagnosis and the belated diagnosis of BH can be explained by the protective role of liver or spleen which may occlude small diaphragmatic defects and prevent the bowel herniation during fetal development [ 8 ]. Although most CDHs present in first 24 hours of life, 5-25% of the patients may have a late presentation [ 3 ].…”