Right-sided Bochdalek hernia causing colon necrosis in a middle-aged woman

MARCH 03, 2008

T. Ferreira, MD
Surgical Resident

A. Lima, MD
Surgical Resident

T. Santos, MD
Surgical Resident

R. Serra, MD
Surgical Resident
Department of Surgery
Serviço de Cirurgia do Hospital de São Sebastião
Santa Maria da Feira, Portugal

ABSTRACT
Introduction: Bochdalek hernias arise during embryological development as a result of improper fusion of the posterolateral foramina of the diaphragm and usually occur on the left side. Although Bochdalek hernia is considered a neonatal disease, it can remain asymptomatic until the patient reaches adulthood.

Results and discussion: The authors report an unusual case of a right-sided Bochdalek hernia that occurred in a 49-year-old woman. They discuss how to diagnose and treat this congenital diaphragmatic defect. They also examine the prevalence of this condition, along with its signs, symptoms, and possible complications.

Conclusion: Chest radiography and computed tomography scanning are the best modalities to use for diagnosing Bochdalek hernias. All Bochdalek hernias must be corrected surgically, even if the patient is asymptomatic. Depending on radiographic and clinical findings, surgeons may elect to employ an abdominal, thoracic, or laparoscopic approach.



The diaphragm is a musculomembranous partition between the abdominal and thoracic cavities. This muscle plays a key role in respiration. It contracts and moves downward as the pectoralis minor and intercostal muscles pull the rib cage outward, giving the chest room to expand. The diaphragm starts developing during week 3 of gestation and is complete by the third month. During embryological development, the diaphragm comprises the following parts: the septum transversum, two pleuroperitoneal folds, cervical myotomes, and the dorsal mesentery. If the pleuroperitoneal canal fails to close between weeks 8 and 10 of gestation, the bowel can become trapped within the thoracic cavity, causing a Bochdalek hernia.

Most Bochdalek hernias are diagnosed in the pediatric population. They are observed primarily in male patients, on the left side, with a male-to-female ratio of 3:2.1 The male preponderance for the less common right-sided congenital diaphragmatic hernias is even more pronounced, with a male-to-female ratio of 3:1.1 We describe an unusual case involving a right-sided Bochdalek hernia in a middle-aged woman.

CASE REPORT

A 49-year-old woman was admitted to the emergency department with multiple symptoms, including paroxystic pain in the superior quadrants of the abdomen; no bowel movement for 5 days, although she was able to pass gas; vomiting; and dyspnea in the right lateral decubitus, which was her only respiratory symptom. The patient reported no history of abdominal or thoracic trauma or recent fever, weight loss, or diarrhea.

 
 

On physical examination, the patient's abdomen was distended, and palpation elicited diffuse pain. Diminished breath sounds were noted at the base of the right lung, and her bowel sounds were tympanic and scarce on auscultation. Digital rectal examination revealed an empty ampulla and no rectal bleeding.

A chest radiograph suggested an intrathoracic colon (Figure 1). Thoracic-abdominal computed tomography (CT) scanning confirmed the presence of a large diaphragmatic hernia, which resulted in contralateral deviation of the mediastinum and collapse of the right lung parenchyma (Figure 2). The hernia appeared to contain a segment of right colon and a significant amount of adipose tissue.

The patient underwent a midline laparotomy, during which the right posterior diaphragmatic hernia was identified. It consisted of a distal segment of the ascending colon, the hepatic flexure, the proximal portion of the transverse colon, and the greater omentum; no hernia sac was identified. The intra-abdominal organs were returned to the abdominal cavity, and the entire herniated colon was noted to be ischemic. The necrotic segments were resected and ileal-colonic anastomosis was performed, after which the diaphragmatic defect was repaired using nonabsorbable continuous sutures and polypropylene mesh. A thoracostomy tube was placed during surgery and removed on postoperative day 8.

The patient had an uneventful recovery and was discharged to home on postoperative day 11. She had regular follow-up examinations in the outpatient clinic for 3 months and reported no symptoms during these visits.

DISCUSSION

Congenital diaphragmatic hernias are birth defects that are most commonly identified in children. They occur in approximately 1 in every 2,000 to 5,000 live births; because they can remain asymptomatic, their true incidence is unknown.2 As of 2001, about 100 cases of occult asymptomatic Bochdalek hernias had been reported in adults.3

Bochdalek hernia is the most common congenital diaphragmatic hernia and accounts for 95% of cases.4 This defect was first described in 1848 by Victor Alexander Bochdalek, a professor of anatomy in Prague.1,5 Morgagni hernias, described decades earlier in 1761, account for approximately 3% of diaphragmatic congenital hernias.6 In contrast to Bochdalek hernias, these hernias are generally located on the right side in the anterior mediastinum due to the retrosternal location of the foramen of Morgagni.7

Associated congenital defects

Between 40% and 50% of congenital diaphragmatic hernias are associated with other malformations, including central nervous system disorders, congenital heart defects, pulmonary hypoplasia, chromosomal abnormalities, and familial syndromes.8 Improvements in prenatal studies have facilitated earlier diagnosis of these conditions, and advancements in medical therapies have increased patient survival rates.

Signs, symptoms, and complications

Signs and symptoms of Bochdalek hernias depend on their size and content. Symptomatic patients most often report dyspnea and thoracic and abdominal pain. Intra-abdominal organs most frequently found to be trapped in the thoracic cavity include the small bowel, ascending colon, transverse colon, left lobe of the liver, and stomach (in 40% of cases).

Patients with Bochadalek hernias are at high risk for complications, which may include intestinal obstruction, gastric volvulus, or vascular compromise of the herniated organs. Our patient presented with symptoms of intestinal obstruction secondary to incarceration of the herniated colon.

Imaging studies

 
 

Chest radiographs may be helpful in diagnosing Bochdalek hernias. According to a study by Swain and associates, chest radiography showed sensitivity for this disorder in 74% of patients.9 Radiographs may depict a lesion that occupies space in the thoracic cavity or intrathoracic intestine. A lateral chest radiograph can demonstrate whether the lesion lies anterior or posterior. In our patient's case, the colon could be visualized within the thorax (Figure 1). CT scanning, however, is the gold standard for confirming a diagnosis of Bochdalek hernia and provides more detailed information concerning the herniated organs. In nonemergency situations, gastrointestinal contrast studies can be performed, but these results could be normal, depending on which organs have herniated.

Treatment

All hernias should be surgically corrected, even in cases where the patient remains asymptomatic. Surgeons can elect an abdominal or thoracic approach or use a combination of the two. The abdominal approach employs a midline incision to allow exploration of the abdominal organs. The thoracic approach is typically used when the liver is involved or the hernia sac strongly adheres to other structures.

Small defects can be repaired using nonabsorbable sutures. If the defect is larger than 5 cm in diameter, mesh should be used to ensure a tension-free repair. Although a variety of materials are available, bilaminar mesh may be beneficial because it integrates on the parietal side and prevents adhesion to structures on the visceral side. We performed median laparotomy on our patient because there was suspected vascular compromise of the herniated segment. The defect was repaired using nonabsorbable sutures and polyethylene mesh was placed above the diaphragm.

Bochdalek hernias and other congenital diaphragmatic defects can be treated laparoscopically. Although laparoscopy has been documented in the treatment of Morgagni hernias since 1994, its reported usefulness in treating Bochdalek hernias is more recent.10 It has been shown to produce successful outcomes and appears to result in fewer sequelae in the immediate postoperative period than open approaches.10

CONCLUSION

Bochdalek hernia is the most common congenital diaphragmatic defect observed in the pediatric population and may be more common in adults than currently reported in the literature. Clinicians should consider this hernia in the differential diagnosis of any patient who presents with a combination of dyspnea and thoracic and abdominal pain. Chest radiography and CT scanning are essential in diagnosing this condition. Once a Bochdalek hernia has been identified, surgical repair is warranted in both symptomatic and asymptomatic patients to prevent future complications.

Disclosure

The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.


References

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