PP102 NON – TRAUMATIC DIAPHRAGMATIC HERNIA MIMICKING TENSION PNEUMOTHORAX

Abstract

NON – TRAUMATIC DIAPHRAGMATIC HERNIA MIMICKING TENSION PNEUMOTHORAX 

MH Mohd Azam¹, N Mohamad Amin¹, N Abdullah¹

¹ Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia

Introduction

Diaphragmatic Hernia can be congenital defect (80%) or traumatic (0.8-1.6%) where right sided is rare (68%) compared to left (80%).

Case Report

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.

Discussion

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. 

Conclusion

Bowel gas collection mimicking tension pneumothorax  causing shortness of  breath is rare clinical presentation of non-traumatic right diaphragmatic hernia.