Title : When acute abdomen crosses the diaphragm: An incarcerated adult bochdalek hernia
Abstract:
Background: Bochdalek hernias are congenital posterolateral diaphragmatic defects that usually present in infancy. Adult presentations are rare and may first manifest with bowel obstruction, strangulation, or ischaemia. Early diagnosis is essential to reduce morbidity and mortality.
Case Presentation: A middle-aged male patient presented to the emergency department with sudden-onset severe generalised abdominal pain that radiated to the back, associated with multiple episodes of vomiting. Examination demonstrated diffuse abdominal tenderness with guarding and rigidity, raising concern for an acute surgical abdomen. Initial investigations revealed raised WCC of 25.9 × 10?/L, lactate of 4.5 mmol/L and a normal CRP. The patient’s past medical history included HIV infection, hepatitis C, and a learning disability.
The patient’s urgent CT abdomen and pelvis demonstrated a large posterior defect in the left hemidiaphragm, with herniation of most of the spleen, splenic flexure of the colon, and multiple jejunal loops into the left hemithorax, consistent with a left-sided Bochdalek hernia. Mesenteric vascular congestion and poor enhancement of the herniated small bowel suggested incarceration. A subsequent CT thorax excluded pneumoperitoneum while confirming mediastinal shift and a left sided pleural effusion.
Management and Outcome: The patient underwent urgent surgical assessment for an incarcerated Bochdalek hernia with suspected bowel compromise. The patient was transferred urgently to a tertiary centre for an emergency laparotomy. The patient's colon, spleen, and most of the small bowel were found within the left hemithorax through an approximately 4 cm posterolateral diaphragmatic defect. Small bowel ischaemia was noted; however, it was deemed viable. The diaphragm was closed using loop PDS sutures and clips. A left sided intercostal drain was inserted for the pleural effusion, and a rectus sheath catheter was also inserted. Postoperatively, patient was sent to HDU to recover, where the patient had NG insertion and sips only for the first 48 hours. The patient continued to recover.
Discussion: Adult Bochdalek hernias are rare and often mimic more common causes of acute abdomen, resulting in delayed diagnosis. This case demonstrates the importance of recognising features of bowel compromise on the CT scans, facilitating urgent transfer and surgical intervention before irreversible bowel necrosis develops, which was successfully done for this patient.
Conclusion: Although rare, Bochdalek hernia should be considered in adults presenting with acute abdominal pain. Early CT diagnosis and prompt surgical management are essential to prevent bowel necrosis and optimise patient outcomes.
