A DELAYED PRESENTATION OF CONGENITAL DIAPHRAGMATIC HERNIA

Abstract

Introduction: Delayed presentation of congenital diaphragmatic hernia (CDH) is uncommon and poses a diagnostic challenge to clinicians.

Case Report: A 2-year-old girl, born premature at 35 weeks, was referred from a district hospital as left lung bullae. She presented with sudden onset abdominal pain, associated with two episodes of non-projectile vomiting and breathlessness since one day prior. On examination, she was tachypnoiec and tachycardic with SpO₂ of 98% on room air. Blood pressure was normotensive. Air entry was reduced on left side chest. Abdominal examination was normal. Initial chest X-ray (CXR) showed a thin-walled radiolucent lesion occupied the left hemithorax which interpreted as left lung bullae, with mediastinal shift to the right. Nasogastric tube (NGT) was inserted but it was not visualized in the left hemithorax to suggest CDH. Consent for chest tube drainage was sought from parents. Nonetheless, they strongly refused despite all risks explained; thus, she was referred to our hospital for further stabilization. At our emergency department, 140mL ‘coffee ground’ fluid and 30mL air were evacuated via manual aspiration of NGT. Ultrasound examination was done, yet the finding was inconclusive. Computed tomography thorax then performed, showed NGT in left thorax inside the left radiolucent lesion which appeared smaller after NGT aspiration. Diagnosis of CDH was established. On laparotomy, a 5cm X 3cm hernial defect was found at left diaphragm antero-laterally with intra-thoracic stomach, greater omentum and splenic flexure of colon. Primary repair of diaphragmatic hernia subsequently followed.

Discussion & Conclusion: CDH may present late with wide spectrum of gastrointestinal or respiratory symptoms. Misinterpretation of initial CXR may lead to unnecessary intervention like thoracocentesis or chest tube drainage. In conclusion, CDH can have delayed presentation beyond neonatal period and should be suspected in any child with abnormal CXR presented with gastrointestinal or respiratory symptoms.