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Interesting Case Presentation Group 4. Personal Data P.B. 71 year old/female Single DOA: December 13, 2009 CC: left lumbar pain.

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Presentation on theme: "Interesting Case Presentation Group 4. Personal Data P.B. 71 year old/female Single DOA: December 13, 2009 CC: left lumbar pain."— Presentation transcript:

1 Interesting Case Presentation Group 4

2 Personal Data P.B. 71 year old/female Single DOA: December 13, 2009 CC: left lumbar pain

3 History of Present Illness Chest Xray: soft tissue mass superimposed by the left cardiac above the medial aspect of the left hemidiaphragm CT Scan: high position kidney herniating through the foramen of Bochdalek 20 years 2 years (+) left sided chest heaviness, aggravated when lying supine No consult

4 History of Present Illness (+) left lumbar pain Consult – UTZ: questionable ectopic kidney – CT Scan: Bochdalek’s hernia (left) minimal pneumonitis inferior lingula, atheromatous aorta, thoracic spondylosis, diffuse osteoporosis, nephrolithiasis, left 1 year 3 months Persistence of symptoms Consult CT Urogram: posterior left diaphragmatic hernia with intrathoracic left renal and colon, herniating, malrotated left kidney



7 Review of Systems No fever, weight loss, anorexia No rash, pruritus No headaches, dizziness No visual disturbance, no colds and cough No diarrhea, no constipation No dysuria, hematuria No polydipsia, polyphagia, polyuria, no heat and cold intolerance No easy bruisability, no bleeding

8 Past Medical / Surgical History (+) Hypertension – maintained on Amlodipine 5mg/tab 1 tab OD No asthma, allergy No DM No previous surgeries or confinements No previous blood transfusion

9 Family History (+) HPN – mother (+) lung disease – mother (+) stroke – brother (+) heart disease – brother (+) goiter – mother (-) DM, asthma, allergy, CA

10 Personal History Non smoker Non alcoholic drinker Denies illicit drug use

11 OB and Menstrual History M: 12 years old I: 28 – 30 days, regular D: 3 days A: 2 ppd/moderately soaked S: (+) dysmenorrhea Menopause at 48 years old

12 Physical Examination Conscious, coherent, ambulatory, not in cardiorespiratory distress BP 130/70 PR 92, regular RR 21, regular T 36.5 Warm moist skin, no active dermatoses Pink palpebral conjunctivae, anicteric sclerae, no palpable lymphadenopathy

13 Physical Examination Symmetrical chest expansion, no retractions, decreased tactile and vocal fremiti on left lower lung field, clear breath sounds Adynamic precordium, AB 5 th LICS MCL, no murmurs Flabby abdomen, NABS, soft, no mass, no tenderness Pulses full and equal, no cyanosis, no edema

14 Salient Features 71 y/o, Female Left lumbar pain Chest heaviness No dyspnea No nausea, vomiting No abdominal pain, distention, tenderness Bochdalek hernia – CT Scan – Urogram decreased tactile and vocal fremiti on left lower lung field No mediastinal deviation

15 Differential diagnosis Other congenital diaphragmatic hernias (Morgani’s) Traumatic diaphragmatic hernia Eventration

16 Morgagni hernias less common CDH 5-10% of CDH cases occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side

17 Eventration of the diaphragm anatomical or functional deficiency of part of the diaphragm, allowing abdominal contents to herniate into the chest more commonly right sided, and affects the anterior portion of the hemidiaphragm

18 Traumatic diaphragmatic hernia Blunt and penetrating traumas cause most acquired diaphragmatic hernias Left-sided rupture is more common than right-sided rupture, owing to hepatic protection and increased strength of the right hemidiaphragm

19 Bochdalek hernias of the diaphragm make up the majority of cases of CDH posterolateral defects of the diaphragm results in either failure in the development of the pleuroperitoneal folds or improper or absent migration of the diaphragmatic musculature

20 Assessment Bochdalek hernia

21 Plans CBC, Na, K 12 L ECG Chest X-ray Exploratory laparotomy with possible thoracotomy

22 Chest X-ray

23 Chest Xray (12/13/09) Both lungs are clear Heart is not enlarged Pulmonary vascularity is within normal limits Left hemidiaphragm is markedly elevated Gas-filled intestines are within the peritoneal cavity There is no definite evidence of Bochdalek hernia Left sulcus and posterior gutter are intact There are moderate hypertrophic changes in the thoracic spine Impression: ELEVATED LEFT HEMIDIAPHRAGM, SUGGESTIVE OF EVANTRATION

24 Spirometry Based on FEV1/FVC ratio, there is no obstructive ventilatory defect. Flow volume loope is scooped out and the FEF 25-75 is low. Suggesting an early obstructive ventilatory defect. Based on the 3% change in FEV1, there is poor response to bronchodilator. There seems to be no associated restrictive ventilatory defect based on normal FVC. For verification we suggest a lung volume study.

25 Blood Chemistry Na137 K3.8 TP7.1 (N 6-7.8) Albumin4.1 (N 4-5.5) Globulin3.0 (N 1.5-3.4) A/G Ratio1.4 CBC Hgb117 Hct0.35 Platelet288 WBC9.40 Neutro0.69 Seg0.69 Lymph0.26 Eo0.05

26 Coagulation Assay PT 10.9s (10.3 -14.1) – NC 12.8 – PT ratio 0.9 – INR 0.9 APTT 29.8 (27.0-45.4) – NC 36.1 s

27 Urinalysis Yellow Clear pH 6.0 SG 1.020 Alb neg Sugar neg RBC 0-2/hpf Bac few

28 ECG Sinus arrythmia

29 OR Done Exploratory laparatomy with primary repair of Bochdalek hernia

30 Bochdalek Hernia

31 Primary Repair

32 OR Findings On opening, the spleen and left colon were mobilized, diaphragmatic hernia was appreciated at the posterior portion of the left hemidiaphragm. The left kidney and splenic flexure were seen herniated through the defect. All the other abdominal organs were grossly normal.

33 Final Diagnosis Bochdalek Hernia s/p primary repair of Bochdalek hernia

34 Discussion

35 Introduction It was first described in 1848 by Bochdalek

36 Embryology Failure of the pleuroperitoneal canal to close at eight weeks gestation

37 Embryology Eighty percent occur on the left side Bilateral, occasionally The defect ranges from a small circular hole (Bochdalek hernia) to total absence of hemidiaphragm

38 Embryology Alter growth of the ipsilateral lung Sometimes, it would alter the contralateral lung (when mediastinum shift to contralateral)

39 Pathogenesis Defective migration of muscle and nerve cell precursors to the diaphragm during formation Diaphragm develops anteriorly as a septum between the heart and liver and then grows posteriorly

40 Final closure is at the left Bochdalek foramen between 8 and 10 weeks GA Bowel migrates from yolk sac to abdominal cavity at 10 weeks If bowel arrive before the foramen closes then hernia can occur

41 Epidemiology Frequency in neonates: 1/7000 Male/female ratio: 3:2 to 2:1 Very uncommon in adult 1992 – 100 cases reported in the literature – Growing use of abdominal CT, increase detection in asymptomatic individuals Luis Bujanda etc 2001~

42 incidence of 0.17% based on 13,138 abdominal CT reports we reviewed. The mean age of the patients was 66.6 years. None of the patients were symptomatic. – Sixty-eight percent of the hernias were on the right side of the body, 18% were on the – left side, and 14% were bilateral. Seventy-three percent contained only fat or omentum, Prevalence of Incidental Bochdalek’s Hernia in a Large Adult Population Mullens Et al Presented at the annual meeting of the Radiological Society of North America, Chicago 2000

43 Bochdalek Hernia Adult Bochdalek hernias are more frequently in women patients (77%) than in men. Contents – 73% intraabdominal fat or omentum only – 27% had solid or enteric organ involvement stomach, liver, spleen (33%), pancreas, or kidney (50%) Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR 2001;177: 363–6.

44 In adults, most Bochdalek’s hernias are likely to be asymptomatic. Hines GL, Romero C. Congenital diaphragmatic hernia in the adult. Int Surg 1983;68:349–351 Previously unrecognized Bochdalek hernia in the adult patient is often diagnosed incidentally to other problems.

45 The most common presentation is left-sided abdominal and chest pain, associated with difficult breathing and intestitial obstruction. Thomas S, Kapur B. Adult Bochdalek hernia: clinical features, management and results of treatment. Jap J Surg 1991; 21(1): 114–119. Sometimes, only gastrointestinal symptoms, caused mainly by obstruction of abdominal viscera. Steenhuis L.H., R.T.O. Tjon A Tham, F.W.J.M. Smeenk. Bochdalek hernia: a rare cause of pleural empyema. Eur Respir J, 1994, 7, 204–206

46 Image examination Chest x-ray (NG tube insertion) Plain abdomen Barium enema study Upper GI barium study Abdominal CT – Most accurate, – Can also detect associated anomalies Abdominal MRI Shin MS, Mulligan SA, Baxley WA, Ho KJ. Bochdalek hernia of diaphragm in the adult. Diagnosis by computed tomography. Chest 1987;92:1098-1101

47 Small, asymptomatic Bochdalek hernia does not require surgical intervention. Shin M S, S A Mulligan, W A Baxley and K J Ho. Diagnosis by computed tomography. Bochdalek hernia of diaphragm in the adult. Chest 1987;92;1098-1101

48 Once diagnosed, the reduction of abdominal viscera in the abdominal cavity is mandatory due to the risk of life threatening complications. Kocakusak A, Arikan S, Senturk O, Yucel AF. Bochdalek’s hernia in an adult with colon necrosis. Hernia 2005;9:284–7.

49 As soon as the diagnosis is made, operative repair should be carried out - even if there are no symptoms - because of the severe complications that large hernias can give, such as strangulation of hernial contents. L.H. Steenhuis, R.T.O. Tjon A Tham, F.W.J.M. Smeenk. Bochdalek hernia: a rare cause of pleural empyema. Eur Respir J, 1994, 7, 204–206

50 Management Aim: Reducing the viscera and sealing the diaphragmatic defect Surgical repair is the most logical management – Laparotomy – Thoracotomy – Laparoscopy – Thoracoscopy – Or combinations

51 Surgical Approach Transthoracic – enables a direct observation of the herniated viscera and allows an easier lysis of the adhesions with the hilum located in the posterolateral region of the diaphragm Transperitoneal – allows the surgeon to confirm the position of the viscera after “pull-back” and to repair any malrotation if present. Masafumi Yamaguchi MD, et al. Thoracoscopic Treatment of Bochdalek Hernia in the Adult: Report of a Case. Ann Thorac Cardiovasc Surg Vol. 8, No. 2 (2002)

52 Complication Volvulus formation Incarceration, strangulation Hemorrhage Perforation of a hollow viscus

53 Prognosis Poor when it is manifested at birth Good in adult (<3% mortality) Poor in adult when complication appear (organ ischemic change, hemorrhage,…)

54 Thank you!

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