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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 113-116
Case report
Congenital diaphragmatic hernia: A rare cause of obstructive jaundice
Dr Manjusha M. litake , Dr Sunil B. Tarode
Sassoon General Hospital and B J Medical College Pune , India
Corresponding author : Dr Manjusha M. litake
Abstract
Congenital Diaphragmatic Hernia in adults are exceedingly rare. They have been reported to cause dyspnea, gastric
reflux and intestinal obstruction .We present the case of a young male with obstructive jaundice secondary to bochdalek hernia of the right hemi-diaphragm. We discuss the aetiologies ,presentation and treatment of the disorder.
Case History
A 29 year old male presented to hospital with
complains of recurrent jaundice (serum bilirubin 27
direct 17 ),icterus, nausea with on and off abdominal
pain. There was no history of trauma. A plain chest
xray taken on admission demonstrated a right lung
collapse and an elevated right hemi-diaphragm.
Ultrasonography of abdomen performed on the same
day demonstrated intrahepatic bile duct dilatation and
herniation of liver, gall bladder, intestines in right
side of thorax.
Due to the dual findings of the chest x-ray and
ultrasonography,
double
contrast
computed
tomography (CT) of the abdomen and thorax was
performed (fig 1). This demonstrated that the right
lobe of liver, gall bladder, kidney and intestinal loops
, mesentery was within the right chest cavity with
kinking of bile duct with collapse of right lung .It
also demonstrated intrahepatic duct dilatation as a
result of anatomical distortion. There was no obvious
pathology in the spleen, left kidney , pancreas ,left
hemi-diaphragm.
Computed tomography of the abdomen and thorax
demonstrating Mild prominence of intra-hepatic
biliary radicals in right lobe of liver, with altered
signal intensity on right lobe of liver suggestive of
obstructive biliopathy. Dilated left hepatic duct with
abrupt narrowing of right hepatic duct at the
confluence suggestive of biliary stricture MRI
Abdomen
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ISSN: 2319-7072
International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 113-116
MRI Abdomen showing large diaphragmatic hernia on right side with herniation of bowel loops, fat right
lobe of liver, gall bladder and right kidney with underlying collapse of lung.
•
Obstructive jaundice reduced within a week
right kidney were seen to be herniating into
of admission without any intervention.It was
thorax. Right lobe of liver was cirrhotic.
decided elective repair of diaphragmatic
•
hernia was needed due the risk of bowel
to junction with left hepatic duct causing
strangulation
biliary obstruction.
or
further
billiary
complications.
•
Intra-operative findings
•
•
E/o kink in right hepatic duct just proximal
Intra-operatively
Right lobe of liver , right kidney & bowel
loops reduced into abdominal cavity,
thoracotomy
and
•
Cholecystectomy done .
paramedian incision was taken for better
•
After reduction of the hernial contents,
exposure .Right lobe of liver was found to
defect was closed and reinforced with an on
be cirrhotic with left lobe hypertrophy.
laying mesh
E/o large defect of size 10×7cm through
abdominal cavity was done.
,primary closure of the
which right lobe of liver, gall bladder and
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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 113-116
Intraoperative photograph showing large defect in the diaphragm with herniation of right lobe of liver and
gall bladder in right hemithorax with cirrhotic right lobe of liver.
Postoperatively Patient electively ventilated .
Patient could not be weaned off ventilator due to collapsed right lung and pulmonary hypertension secondary to lung
hypoplasia.
On day 3 patient had deranged Liver Function Tests Serum Bili-rubin 12.3(Direct 7.3)
SGOT(354)
SGPT(447)
Died due to acute on chronic liver Failure on postoperative day 4.
Discussion
hernias. There have been fewer than 100 cases of
Congenital diaphragmatic hernia (CDH) is very rare
adults presenting with a complication of congenital
with an incidence of between 1 in 2,500 to 12,000
diaphragmatic hernias in the literature and none
1
live births. The majority (85%) occur in the postero-
presenting with obstructive jaundice. There are two
lateral area of the hemi-diaphragm (Boch-dalek
reported
hernia), resulting from the persistence of the pleuro-
obstructive jaundice secondary to a Boch-dalek
peritoneal canal owing to the non-fusion of the
hernia.7,8
pleuro-peritoneal folds during the eighth week of
Here we present the case of a young male with a rare
2
cases
of
neonates
presenting
with
gestation. This is almost always an emergency as the
congenital right-sided Bochdalek hernia. There was a
vast majority present with respiratory distress and
delay in the diagnosis because of the initial
sepsis in the newborn.
presentation of recurrent jaundice.
CDH in adulthood is exceptionally rare with a rate of
3
Investigation by chest x-ray alone is not enough to
0.17% found incidentally on CT. Complications
make the diagnosis although a chest radiograph after
resulting from Boch-dalek hernias in adults can
nasogastric tube placement could have expedited the
include
bowel
4
obstruction, gastric
5
reflux and
diagnosis. CT provided a detailed assessment of the
6
pancreatitis. These are almost exclusively left-sided
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ISSN: 2319-7072
International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 113-116
anatomy and a cause for the obstructive jaundice was
complications.10Possible postoperative complications
established.
include abdominal compartment syndrome although
Even though CDH has been well described in the
there is no evidence in the literature to support this.
literature, the incidence of clinical presentations in
Conclusions
adulthood is exceedingly rare and this is the first case
CDH is exceedingly rare in adulthood and has been
of it leading directly to obstruction of the biliary
reported to become symptomatic in only a handful of
system. Open mesh repair of the hernia is the gold
cases. However, since its presence can lead to serious
standard treatment option with evidence to back up
adverse events such as acute intestinal obstruction, or
its safety and efficacy. There are very few
in this case obstruction of the biliary system, it
documented cases of successful laparoscopic repair
should be investigated fully and repaired rapidly. The
of an adult CDH in the literature. One case series
diagnosis should be considered in any patient
suggests that this is a safe alternative treatment
presenting with abdominal pain and an unexplained
modality for CDH presenting past infancy.
9
consolidation on a chest x-ray.
Current recommendations are that all adults with a
CDH
undergo
repair
in
order
to
avoid
References
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