INTRODUCTION: Blood in the pleural fluid is often an ominous sign of an underlying life-threatening disease entity, most commonly malignancy, infection, or embolism. Diaphragmatic hernias are also a well documented cause, whether congenital in children or traumatic in adults. Rarely, it can be caused by non-traumatic diaphragmatic hernia in adults. Here we describe a case of a hiatal hernia causing bloody pleural effusion.
CASE PRESENTATION: An 87-year-old Caucasian male with history of chronic obstructive pulmonary disease and hypertension who underwent gastropexy for incarcerated gastric hernia two years prior to this encounter, presented to the emergency department with symptoms of dyspnea, weakness, and confusion. On exam, he was hypotensive with wheezes bilaterally and decreased breath sounds at the right lung base. Bowel sounds were hypoactive. Chest x-ray revealed infiltrates on the right side consistent with pneumonia and possible pleural effusion. He was admitted to the intensive care unit and started on antibiotics. The next morning, chest x-ray revealed significant worsening of his pleural effusion. Computed tomography images of the chest revealed the large pleural effusion as well as multiple loops of dilated small bowel. On thoracentesis, about 1000 ml of serosanguinous pleural effusion was evacuated. Patient was subsequently taken to the operating room as there was a high concern for necrotic bowel in the chest. After attempts at reducing the hernia by laparatomy were unsuccessful, thoracotomy was performed. In addition to bloody effusion, a significant amount of black-colored small bowel was found to be trapped in the chest. Necrotic bowel was resected and pleural effusion was drained. Thereafter, patient had a slow recovery, but no recurrence of pleural effusion.
DISCUSSION: Traumatic diaphragmatic hernia has been associated with bloody pleural effusions but there have been very few cases unrelated to trauma in adults. There has been case reports published of non-traumatic diaphragmatic hernias and late onset Bochdalek hernias causing bloody pleural effusion. The proposed mechanism is that there is extravasation of blood from stasis due to omental strangulation, which likely explains the findings in our patient. Although our patient had no symptoms of obstruction, studies have shown the presence of asymptomatic diaphragmatic hernias, found incidentally on imaging, in up to 0.17% of adult subjects.
CONCLUSIONS: Blood in the pleural fluid may provide an additional clue to consider incarcerated diaphragmatic hernia in the differential diagnosis. Our patient is the first documented case to our knowledge of specifically a hiatal hernia causing bloody pleural effusion without history of trauma.
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Reference #2 Schreier L, Cutler RM, Saigal V. Bloody pleural effusion secondary to infarction of omentum through a non-traumatic diaphragmatic hernia. Chest.1988 Jun; 93(6):1314.
Reference #3 Shimizu T, Hira S, Hirooka S, Yonekura T, Tamai H. Late onset of right Bochdalek's hernia with strangulation of the omentum. Acta Paediatr. 2002; 91(4):483-5
DISCLOSURE: The following authors have nothing to disclose: Muhammad Siddique, Jonaid Aslam, Mohammad Syed, Misbat Chaudry, Joseph Henkle
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