Imaging |

Triple Whammy! Intercostal Herniation of Lung, Liver, and Colon FREE TO VIEW

Brijesh Patel, MD; Umar Sofi, MD
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Carilion Clinic/Virginia Tech Carilion School of Medicine, Roanoke, VA

Chest. 2015;148(4_MeetingAbstracts):503A. doi:10.1378/chest.2269423
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SESSION TITLE: Imaging Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Lung herniation occurs infrequently. Transdiaphragmatic Intercostal Herniation (TIH) of abdominal contents has rarely been reported. We present a complex case of lung, liver and colon herniation through the same intercostal space.

CASE PRESENTATION: A 47 year-old man with a history of COPD and seizures, presented after a fall with dyspnea and right chest wall pain. Physical exam showed large ecchymosis over the right flank. Thoracic CT demonstrated herniation of the lung and a portion of the liver through the 8th rib space. Cardiothoracic surgery (CTS) recommended elective repair of the defect after optimization of pulmonary status. He was subsequently discharged home. A week later, he was readmitted with worsening dyspnea and a soft, reducible mass over the right posterior chest wall that decreased and increased in size with inspiration and expiration respectively. Thoracic CT revealed pleural effusion contiguous to the herniated lung with new airspace disease. Thoracentesis yielded a large amount of serosanguinous fluid. He was treated for HCAP and discharged with a chest brace. Two weeks later, he presented to the ER with severe abdominal pain. CT scan revealed interval enlargement of the above hernia, TIH of mesenteric fat and ascending colon with evidence of incarceration. He was emergently taken to the OR and underwent successful reduction and repair of the incarcerated hernia. He is now awaiting evaluation for the intercostal defect repair.

DISCUSSION: Fewer than 300 cases and 40 cases of lung herniation and TIH have been reported in literature respectively.(1) The majority of cases are acquired and occur after a blunt trauma. While diaphragmatic injury should be suspected in all cases of intercostal herniation,(2) prompt and precise diagnosis can be made by CT scan. Although, small hernias seldom regress spontaneously,(3) management can be complex. Definitive treatment can be achieved through surgical repair.(1)

CONCLUSIONS: Intercostal lung herniation is rare and even rarer in conjunction with TIH of abdominal contents. We present an intricate case with unexpected complications of pneumonia, pleural effusion and incarceration with the management challange of this rare entity.

Reference #1: Sharma OP, et al. “TIH: review of the world literature and presentation of a case,” Journal of Trauma, vol. 50, no. 6, pp. 1140-1143, 2001

Reference #2: Sarkar D, et al. “TIH following Blunt Trauma,” Case Reports in Radiology, vol. 2012, Article ID 502765, 4 pages, 2012

Reference #3: Weissberg D. Lung hernia - a review. Adv Clin Exp Med 22: 611-613; 2013

DISCLOSURE: The following authors have nothing to disclose: Brijesh Patel, Umar Sofi

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