NON – TRAUMATIC DIAPHRAGMATIC HERNIA MIMICKING TENSION PNEUMOTHORAX
MH Mohd Azam1, N Mohamad Amin1, N Abdullah1
1 Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia
Diaphragmatic Hernia can be congenital defect (80%) or traumatic (0.8-1.6%) where right sided is rare (68%) compared to left (80%).
A 71 year old gentleman, known hepatocellular carcinoma presented with shortness of breath, and abdominal distention. He was alert, lethargic, tachypneic, tachycardic with borderline blood pressure. Right lung was hyperresonance with reduced air entry and trachea deviated to the left side. Abdomen was distended but non tender. Chest x-ray showed trachea was deviated to the left with huge right pneumothorax with query bowel shadows seen at right lower zone. CT thorax showed a defect of 7.0 x 6.1 cm at anterolateral of right hemidiaphragm causing herniation of bowel into whole right thoracic cavity with lung collapse and left mediastinal shift . Ultrasound guided pleural tapping followed by thoracostomy drained a foul smelling gas and hemoserous fluid. Repeated chest X-ray showed trachea central with bowel shadows at right hemithorax.
Lung metastatic with tension pneumothorax or bullae was suspected initially causing breathlessness. The bowel shadow was not appreciated initially in CXR till discussion with radiologist whereby right diaphragmatic hernia was confirmed by CT thorax. Ultrasound guided pleural tapping to release the thoracic pressure is lifesaving with caution not to injured the bowels.
Bowel gas collection mimicking tension pneumothorax causing shortness of breath is rare clinical presentation of non-traumatic right diaphragmatic hernia.
Non Traumatic Right diaphragmatic hernia; Adult; Computed Tomography; Chest Tube; Pleural Tapping
2. Enrica Bianchi et al; (2015); Congenital asymptomatic diaphragmatic hernias in adults; a case series.
3. Mullins ME et al; (2001); Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR Am J Roentgenol 177(2):363-366
4. Sanjay K. Somani et al; (2011); Bochdalek diaphragmatic hernia masquerading as tension hydropneumothorax in an adult; Volume 141(1):300-301