INTRODUCTION
Diaphragmatic hernia commonly occurs in the neonates due to a congenital defect of diaphragmatic muscles (Al Ghafri et al. 2014). It will lead to herniation of abdominal content into the thoracic cavity. The herniated content can be in the form of hollow or visceral organs. Hence, it will manifest as cardio-pulmonary symptoms and failure to thrive among children (Sathyanarayana et al. 2012). It is very uncommon with a rate of 1 : 2500-3000 live births (Malekzadegan & Sargazi 2016). In 20% of cases, the diaphragmatic hernia can occur on the right side and 80% of subjects is on the left side (Malekzadegan & Sargazi 2016). The diaphragm is rarely engaged on both sides. However, it is vice versa among chronic idiopathic diaphragmatic hernia as it is more common to happen on the right side (Ayane et al. 2017).
It is known as Bochdalek hernia if the diaphragmatic defect occurs at the postero-lateral part and Morgagni hernia if at the anterior or central part, in which the former is found more common as compared to the latter (Malekzadegan & Sargazi 2016). In adults, a diaphragmatic hernia is easily identified among post-trauma patients, usually on the left side. However, it is deemed rare to present without any precipitating factors, especially in the elderly (Murchite et al. 2020). A late presentation of diaphragmatic hernia is perplexing especially without aetiology. We report a 68-year-old male who presented to us with an acute intestinal obstruction secondary to a right diaphragmatic hernia and we discuss our immediate successful management for this man.
CASE REPORT
A 68-year-old male presented to the Emergency Department with a 4-day history of acute intestinal obstruction. He had a change of bowel habit accompanied by constitutional symptoms for the past one month but no other alarming signs of malignancy. He denied any history of trauma, fall or motor vehicle accident. Upon assessment, he was dehydrated but haemodynamically stable. He was neither pale nor jaundiced. Clinically, the abdomen was distended with generalised tenderness and no palpable abdominal mass. The bowel sound was hyperactive. The breath sound was absent on the right side as compared to the left. Digital rectal examination showed an empty rectum with no palpable mass.
Blood investigations were within normal range except for a slight acute kidney injury picture. The chest and abdominal radiography revealed a bowel loop in the right chest cavity with a dilated small bowel in the abdomen. The computed tomography (CT) scan was consistent with a diaphragmatic hernia and acute intestinal obstruction (Figure 1 & 2). The patient was posted to the operating theatre for an emergency laparotomy. The anaesthetic management was a rapid sequence induction followed by the insertion of a right-sided double-lumen tube (DLT) size 27 Fr to decompress the right lung. Intraoperatively, a small right sided defect was identified measuring 5 cm x 4 cm in size with small bowel herniated through it. The herniated bowel was reduced back into the abdominal cavity. It was repaired via an interrupted technique of non-absorbable suture. A chest tube was inserted into the right pleural space prior to the abdominal closure. He recovered well postoperatively. One month later, he had no more bowel or respiratory symptoms.
DISCUSSION
Delayed presentation of congenital diaphragmatic hernia is postulated to occur after initial resistance by the liver from the displacement of abdominal contents into the thoracic cavity (Ayane et al. 2017). Apart from the classical symptoms of intrathoracic compression such as shortness of breath and reduced effort tolerance, patients can present with the classical triad of intestinal obstruction namely colicky abdominal pain and distension, vomiting and no bowel opening. Our patient had shown more of intestinal manifestations rather than cardio-respiratory symptoms.
The nonspecific symptoms can be intriguing, hence leading to a wrong diagnosis and inappropriate intervention. Occasionally, the acute presentation of cardio-pulmonary symptoms after trauma can be confused with tension pneumothorax. The unnecessary or improper insertion of a chest drain may result in serious complications of intrathoracic abdominal visceral injury (Mathai & Singh 2011).
Late-onset of congenital diaphragmatic hernia can be diagnosed by various radiological methods. Imaging modalities such as chest radiography, ultrasonography, contrast study, CT scan and magnetic resonance imaging (MRI) are beneficial to diagnose such conditions (Al Ghafri et al. 2014). A coiled nasogastric tube in the thoracic cavity can be visualised following chest radiograph. Presence of bowel gas shadow loops in the thoracic cavity in the absence of diaphragmatic outlines is radiologically diagnostic for diaphragmatic hernia.
Various imaging modalities such as chest radiography, ultrasonography, contrast study, CT scan and MRI, have been reported helpful in cases of diaphragmatic defect (Al Ghafri et al. 2014). Chest radiograph remains the best initial imaging with specific diagnostic findings of intrathoracic bowel herniation or a coiled nasogastric tube above the hemidiaphragm (Iochum et. al. 2002). However, in terms of visualising diaphragmatic defect, multidetector CT with multiplanar reconstruction in sagittal and coronal planes is highly accurate in diagnosing traumatic diaphragmatic rupture with sensitivity of 100% and specificity of 93% (Magu et al. 2012). MRI is also reported to be helpful in special cases of uncertain diaphragmatic defects (Sandrine et. al. 2002).
Intraoperatively, the anaesthetic team plays a vital role in ensuring the patient safety and smoothness of surgery. The patient needs to be ventilated using the DLT, hence the affected lung can be collapsed while maintaining oxygenation via the contralateral side (Tan et al. 2020). The principles of surgical treatment for strangulated diaphragmatic hernia encompass; (i) reduction of abdominal contents, (ii) resection of ischemic bowel, (ii) closure of the diaphragmatic defect and (iv) restoration of intrathoracic pressure with a chest drain. However, in managing late presentations of congenital diaphragmatic hernia, failure to detect, investigate and treat early can result in mortality rates as high as 30% (Ayane et al. 2017).
CONCLUSION
This case highlights the variety of manifestations of the late onset of congenital diaphragmatic hernia. It emphasises the vital functions of perioperative management which consist of precise clinical assessments, good imaging modality, perioperative management as well as urgent surgical correction.