THE UNEXPECTED BLACK HOLE

Abstract

INTRODUCTION

Abdominal pain is poorly understood and expressed by children, posing a challenge in history taking and diagnostic dilemma. We discuss a case of a child presenting with abdominal pain which was mismanaged and led to an unexpected finding.

CASE REPORT

A 2-years 6-months old boy, previously well, was brought to the emergency department for abdominal pain for 5 hours duration. It was described as intermittent and colicky in nature. There was no fever, trauma nor gastrointestinal losses. Physical examination was unremarkable and the vital signs were stable. The child was prematurely discharged. He progressively became less active and was brought back 8 hours later with no signs of life. Resuscitative efforts were unfruitful. Post mortem radiograph revealed a white-out left hemi-thorax with mediastinal shift and left-sided pneumoperitoneum. Autopsy showed left posterior pleuraperitoneal defect, with a diaphragmatic hernia. The stomach was in the left thoracic cavity, with a 0.5cm perforation and 100cc of gastric fluid.

DISCUSSION

It is challenging to obtain a proper history from young children especially regarding the nature of abdominal pain, leading to difficulties in diagnosing them. Congenital Diaphragmatic Hernia (CDH) is a very rare condition, occurring 1 in 3300 live births, presenting with respiratory symptoms. Only 20% of CDH occur with late presentation beyond the neonatal period, while 5% presented with vague abdominal symptoms, with no abdominal findings. Prognosis is excellent if detected and managed early, but mortality rate is high in late presentation. Sudden deterioration is attributed to vagal stimulation and obstructive shock contributed by the increased gastric pressure in the thoracic cavity.

CONCLUSION

A normal physical finding in a child with abdominal pain should never be taken lightly. It may reveal the unlikeliest of diagnosis. High index of suspicion should be warranted.