Background

Congenital diaphragmatic hernia (CDH) is an anomaly that occurs in 1 in approximately 3000 live births.1 The commonest form is the posterolateral or Bochdalek hernia.1 The condition typically manifests in early childhood with life-threatening complications, but the diagnosis may be delayed beyond the neonatal period in some cases.2 It is very rare in adults, however, complications resulting from Bochdalek hernia occurring in the geriatric age group have been reported.3 Most adults with congenital diaphragmatic hernias have either asymptomatic herniation or a defect without any herniated viscera.4 An incidental rise in intrabdominal pressure for any reason may cause the herniation that elicits symptoms. An example of this is upper gastrointestinal tract (GIT) endoscopy where air is insufflated in the stomach to facilitate the procedure. We report a rare case where herniation of abdominal contents followed upper GIT endoscopy in a previously asymptomatic adult with congenital diaphragmatic hernia.

Case presentation

A 27-year-old man who had no medical history of note was referred to a gastroenterologist with a 10-day history of epigastric pain. He underwent upper gastrointestinal tract endoscopy, which revealed an inflamed duodenal ulcer for which he was prescribed omeprazole and full eradication therapy. At 5 days later he developed coffee ground vomitus and became short of breath. He was admitted to hospital and was given intravenous fluids and antibiotics. A chest x ray (fig 1) was performed and, on analysis of the radiograph, he was referred to the respiratory ward for management as a case of hydropeumothorax. Physical examination revealed an ill-looking man who was breathless but not cyanosed; he had sinus tachycardia (heart rate 110 beats/min) and was normotensive (blood pressure 120/75 mm Hg). The left side of the chest was moving less and there were signs of mediastinal shift to the right side with tactile vocal feramitus less on the left side, and the percussion note was increased over the left upper chest and dull over the left lower chest. Succussion splash was positive. On reviewing the chest x ray, CT of the chest (fig 2) and a barium meal study (fig 3) were performed. At this stage it was clear that the diagnosis was one of gastrothorax. The patient was operated on and the operative findings were stomach and ascending colon were found herniating through a defect at the posterolateral aspect of the left hemidiaphragm. The stomach and colon were returned to the abdomen and the diaphragmatic defect was closed. The patient had an uneventful postoperative recovery and when seen in our clinic 2 months later he remained well and was discharged from follow-up.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Chest radiograph showing the herniated stomach in the left hemithorax with air–fluid level (black arrow) and shift of the mediastinum to the right side (white arrow).

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

CT scan of the chest showing the herniated stomach displacing the mediatinum to the right.

• Download figure
• Open in new tab
• Download powerpoint

Figure 3

Barium meal showing herniated stomach and colon inside the chest.

Outcome and follow-up

The patient made an uneventful recovery following surgery and remained well when seen in our clinic 2 months after surgery.

Discussion

Numerous complications of a delayed CDH have been reported in children, including respiratory distress, small or large bowel obstruction and strangulation, and gastric volvulus.5^,6 A posterolateral congenital diaphragmatic defect may become symptomatic later in adult life, causing abdominal and/or respiratory symptoms.3^,7 There has been at least one case report of gastrothorax during upper GIT endoscopy in a patient with an asymptomatic CDH.3 The case we report is different in that our patient was not in circulatory collapse although there were clinical and radiological signs of mediastinal shift. Cardiorespiratory collapse in gastrothorax possibly occurs when there is stomach overinflation, causing restriction of cardiorespiratory function as occurs in a tension pneumothorax. In our patient there may not have been enough stomach overinflation to cause cardiorespiratory compromise and the good cardiorespiratory reserve in a young man may have prevented this happening. Nevertheless, this case report highlights that a spectrum of clinical presentations may be seen in this condition. Another difference between our case and the one reported by Ninos et al3 is that there was a delay of presentation from the time of endoscopy. A possible explanation for this is that a degree of herniation was triggered by endoscopy and this herniation was made worse by continuous vomiting, causing a further increase in intra-abdominal pressure and more herniation.

One more point that deserves discussion is that the physical and radiological signs of gastrothorax very much mimic a pneumothorax or a hydropneumothorax; indeed this patient was referred to the respiratory ward for management of a hydropneumothorax. Inserting a chest tube in this patient would have been disastrous, causing gastric and/or colonic perforation. A high index of suspicion and a thoughtful approach are required to diagnose complications arising from an asymptomatic CDH in an adult.