INTRODUCTION: Bochdalek hernias are a rare entity, occurring in 1 out of 2,200 to 12,500 live births. Some may be detected early in childhood due to respiratory distress, but others may not be discovered until later on in life, if at all. This case report demonstrates the importance of Bochdalek hernias in the setting of abnormal thoracic imaging in symptomatic patients.
CASE PRESENTATION: 79 year old male with a past history of hyperlipidemia, melanoma post removal many years ago, and recent boating accident 6 months ago in which he sustained several rib fractures on his left side presents with 2 days of nausea, vomiting, diarrhea, and left upper quadrant abdominal pain which radiates to the flank. He denies fever, chills, blood in the stool, recent travel. His exam was positive for left upper quadrant tenderness, left basilar crackles, and fever. He was admitted, CT scan of the abdomen performed, which showed segmental thickening and inflammatory changes at the splenic flexure. He was started on broad spectrum antibiotics for concern of diverticulitis. During his hospitalization, he had sudden onset shortness of breath, and a chest film was obtained showing a pneumothorax. A chest tube was placed, and drained brown material which grew E. coli and Enterococcus. He became septic necessitating pressor support. A larger bore chest tube was placed with improvement in his status. He subsequently underwent VATS due to concern of empyema or rind seen on a repeat CT chest. Multiple chest tubes continued to drain large amounts of brown material. He then underwent a thoracotomy, where a diaphragmatic hernia was noted and his colon was found in the thorax, perforated and leaking feculent material. He had diaphragmatic hernia repair along with colectomy with subsequent lung re-expansion.
DISCUSSIONS: Bochdalek hernias arise from the failure of the pleuroperitoneal space to close prior to the return of bowel to the abdomen in week 8-10 of development. Although some are diagnosed at birth due to dyspnea or other respiratory symptoms, others remain asymptomatic or are acquired with increased intra-abdominal pressures such as retching, coughing, pregnancy, or trauma. There are approximately 105 case reports of symptomatic Bochdalek hernias in the adult population. CT scans appear to be the most sensitive for detection of hernias but are often mistaken for other intrathoracic pathology, complicating or delaying the diagnosis. In our patient, we theorize that he had a diaphragmatic opening due to a Bochdalek defect with subsequent herniation of bowel during his boating accident. The incarcerated bowel became necrotic and perforated causing his symptoms, including his pneumothorax and empyema. The lateral and posterior nature of Bochdalek hernias make detection during VATS difficult, as was the case in our patient.
CONCLUSION: Bochdalek hernia is an extremely rare cause of empyema in adults. Presentation and imaging may be nonspecific, making it challenging to diagnose. Surgical correction is recommended whenever it is encountered to correct or prevent complications.
DISCLOSURE: Kristine Kuhl, No Financial Disclosure Information; No Product/Research Disclosure Information