Description

A 68-year-old woman presented with a 4-week history of right-sided chest pain and dyspnoea on minimal exertion. These symptoms had begun immediately after sudden twisting and lateral flexion movements of her trunk. She denied previous blunt or penetrating trauma. The patient was born at term and delivery was normal. She had remained asymptomatic until the present hospital admission; specifically, she denied chronic dyspnoea, chest pain, vomiting, abdominal pain and postprandial fullness. Seven years earlier, a CT study had been performed to ascertain the origin of a possible right subdiaphragmatic abnormality identified on a radiograph. CT scan only disclosed a normal variant of the right liver lobe. Physical examination only revealed abolition of breath sounds on the right lower hemithorax. Chest x-ray film showed an apparent right-sided pleural effusion (figure 1A) but thoracic ultrasound scan did not confirm this suspicion. Reformatted coronal (figure 1B) and sagittal (figure 1C) CT scans revealed protrusion of bowel loops and mesenterium into the posteromedial region of the right hemithorax through a right posterior diaphragmatic defect (thick arrows indicate the diaphragmatic hiatus). Such findings were consistent with Bochdalek hernia. Moreover, thoracic and abdominal CT showed no other congenital abnormalities. After moving back the hernia sac and the protruded organs (jejunum, ileum, part of right colon and mesenterium) to the abdominal cavity she underwent surgical diaphragmatic repair. Recovery was uneventful and the patient was discharged 12 days after the operation. Posterior transdiaphragmatic (Bochdalek) hernia was first described in 1848 as a neonatal period disease.1 2 Most of the Bochdalek hernias are placed on the left side and appear in children who present with acute respiratory symptoms.3 Although uncommon and often incidental in adults, this abnormality should be known and managed suitably to avoid potential complications—strangulation of the hernia contents, intestinal necrosis, haemothorax, pneumothorax.3

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Figure 1

Chest x-ray of the patient (A) shows a possible right-sided pleural effusion. Reformatted thoracic CT scan (B) coronal section; (C) sagittal section demonstrates protrusion of abdominal contents into the right hemithorax through a posterior diaphragmatic defect. DH, diaphragmatic hiatus; LD, left diaphragm; LL, left lung; Mes, mesenterium; RC, right colon; RD, right diaphragm; RL, right lung; SB, small bowel.