Strangulated diaphragmatic hernia presenting clinically as pericarditis

A case of strangulation of the transverse colon in a traumatic left diaphragmatic hernia manifesting as pericarditis is reported. This is unusual because pericardial signs in traumatic diaphragmatic hernia have been previously described in association with direct pericardial injury. This is the only such case where electrocardiographic changes of pericarditis were seen without direct pericardial trauma. The possibility of internal herniation through a traumatic diaphragmatic hernia must be considered in patients with chest symptoms and a compatible history.     

Congenital diaphragmatic hernia presenting as massive gastrothorax

Delayed herniation of abdominal contents through a congenital diaphragmatic hernia may occur beyond the neonatal period. The case of a 29-month-old child with a Bochdalek hernia presenting as acute respiratory failure is presented. Chest radiography showed a tension gastrothorax that was misread as a tension pneumothorax. Tube thoracostomy resulted in clinical improvement by perforating and decompressing the stomach. Nasogastric tube placement confirmed herniation of the stomach into the left chest and is the initial treatment of choice when a tension gastrothorax is identified. A congenital diaphragmatic hernia must be recognized promptly so that rapid gastric decompression and surgical repair of the diaphragmatic defect can be performed.     

Traumatic diaphragmatic hernia presenting as a chest wall mass

A patient with traumatic diaphragmatic hernia had his lesion present remotely after thoracoabdominal trauma as an asymptomatic chest wall mass. This is a rare and, perhaps, unique presentation of this entity.     

Colopleural fistula presenting as tension pneumothorax in strangulated diaphragmatic hernia

A case of colopleural fistula, resulting from strangulation and perforation of a diaphragmatic hernia and presenting as tension pneumothorax, is reported. The hernia was most likely a consequence of a stab wound to the left side of the chest four years before admittance. Colopleural fistula as a cause of tension pneumothorax is an extremely rare entity, reported only once in past English medical literature.     

A case of traumatic diaphragmatic hernia presenting a distinct thoracic abnormal shadow after a long course of disease

A 43-year-old man came to our hospital for further examination of a thoracic abnormality pointed out on a check-up examination. Chest X-ray revealed a protruding tumor shadow on the right diaphragm. The patient had a history of right precordial contusion due to a traffic accident about 2 years previously, and after the injury a shadow appeared which gradually became larger, suggesting traumatic right diaphragmatic rupture-induced hernia. Chest CT scan revealed middle hepatic vein within the tumor without changes such as deviation and/or stenosis and hepatoparenchymatous tumor. Ultrasonography revealed the tumor to comprise a part of the liver (S4, S8) with the normal internal echo and the right diaphragm dividing the liver parenchyma in two, intrathoracically and intraperitoneally. The above led to the diagnosis of right diaphragmatic hernia, which probably was caused by the traffic injury and gradually increased during approximately 2 years. In cases of suspected traumatic right hemidiaphragmatic hernia, ultrasonography is regarded as useful.     

The cardiac silhouette

The cardiac silhouette as seen on a routine chest film contains considerable information regarding the presence of heart disease, the nature and severity of the disease, and its prognosis. The changes that are seen directly reflect the altered anatomy and physiology of the heart. Appreciation of these factors allows for a reasonable, logical approach to interpretation of the cardiac silhouette.     

Absence of cardiac hypoplasia in an experimental model of congenital diaphragmatic hernia]

INTRODUCTION: Congenital diaphragmatic hernia (CDH) is a rare malformation in newborns. Amongst the various prenatal prognostic criteria, it is suggested that heart weight could be useful in evaluating the severity of lung hypoplasia. In this work we studied heart development in a rat model with nitrofen-induced CDH. MATERIAL AND METHODS: Pregnant female Wistar rats were treated on day 9 1/2 of gestation with 100 mg of nitrofen dissolved in 1 ml of olive oil. The control group was only treated with 1 ml of olive oil. The foetuses were delivered by caesarean section on day 21 1/2 of gestation. The weight of the foetuses was recorded. Under microscopy, the foetuses were dissected and the diaphragm was inspected. The wet weight of the heart and lung were recorded. The results are presented as a mean +/- standard deviation. A statistical analysis was made with the one-way ANOVA test on Ranks, and the Dunn test for post-test analysis. The statistical significance was set at a p < 0.05. RESULTS: The foetuses with CDH (n = 16) were lighter and had a smaller left lung/body weight ratio when compared with animals exposed to nitrofen without CDH (n = 18) and with controls (n = 12) (p < 0.05). The heart/ body weight ratio was smaller in foetuses exposed to nitrofen (p < 0.05), but we could not find any differences between nitrofen-treated treated foetuses with vs without CDH (n.s.). CONCLUSIONS: In spite of the lung hypoplasia, we could not demonstrate the presence of heart hypoplasia in rats with CDH when compared to nitrofen-treated foetuses without CDH.     

Delayed traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade

We describe a case of delayed presentation of traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade. A 71-year-old woman presented to our emergency department complaining of epigastric and midabdominal pain one month after hospitalization for multiple injuries suffered in an automobile accident. Chest radiograph showed a diaphragmatic hernia. In the ED, the patient became hypotensive and tachycardic with elevated central venous pressure. At surgery, she was found to have omentum and transverse colon herniated into the pericardial sac causing cardiac tamponade. The defect was repaired, and her postoperative course was uncomplicated. Cardiac tamponade should be included in the differential diagnosis of hypotension in patients with radiographic evidence of diaphragmatic hernia.     

Congenital diaphragmatic hernia misdiagnosed as tension pneumothorax

Drainage of the pleural space is undertaken as an emergency when there is respiratory distress and the radiological appearance of mediastinal shift. We present two cases in which the initial diagnosis was tension pneumothorax and chest drains were inserted. In both cases, the diagnosis turned out to be congenital diaphragmatic hernia. Pediatr. Pulmonol. 1997;24:119–121. © 1997 Wiley-Liss, Inc.     

Mouse lacking COUP-TFII as an animal model of Bochdalek-type congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH), a life-threatening anomaly, is a major cause of pediatric mortality. Although the disease was described >350 years ago, the etiology of CDH is poorly understood. Here, we show that tissue-specific null mutants of COUP-TFII exhibit Bochdalek-type CDH, the most common form of CDH. COUP-TFII, a member of orphan nuclear receptors, is expressed in regions critical for the formation of the diaphragm during embryonic development. Ablation of COUP-TFII in the foregut mesenchyme, including the posthepatic mesenchymal plate (PHMP), results in the malformation of the diaphragm and the failure of appropriate attachment of the PHMP to the body wall. Thus, both the stomach and liver enter the thoracic cavity, leading to lung hypoplasia and neonatal death. Recently a minimally deleted region for CDH has been identified on chromosome 15q26.1-26.2 by CGH array and FISH analysis. COUP-TFII is one of the four known genes residing within this critical region. Our finding suggests that COUP-TFII is a likely contributor to the formation of CDH in individuals with 15q deletions, and it may also be a potential contributor to some other Bochdalek-type of CDH.     

Congenital diaphragmatic hernia

Infants with congenital diaphragmatic hernia (CDH) have significant mortality and long-term morbidity. Only 60-70% survive and usually those in high-volume centres. The current Task Force, therefore, has convened experts to evaluate the current literature and make recommendations on both the antenatal and post-natal management of CDH. The incidence of CDH varies from 1.7 to 5.7 per 10,000 live-born infants depending on the study population. Antenatal ultrasound scanning is routine and increasingly complemented by the use of magnetic resonance imaging. For isolated CDH, antenatal interventions should be considered, but the techniques need vigorous evaluation. After birth, management protocols are often used and have improved outcome in nonrandomised studies, but immediate intubation at birth and gentle ventilation are important. Pulmonary hypertension is common and its optimal management is crucial as its severity predicts the outcome. Usually, surgery is delayed to allow optimal medical stabilisation. The role of minimal invasive post-natal surgery remains to be further defined. There are differences in opinion about whether extracorporeal membrane oxygenation improves outcome. Survivors of CDH can have a high incidence of comorbidities; thus, multidisciplinary follow-up is recommended. Multicentre international trials are necessary to optimise the antenatal and post-natal management of CDH patients.     

Congenital diaphragmatic hernia

Chronic endobronchial infection frequently caused by gram-negative organisms and an increased, neutrophil-dominated inflammation are characteristics of cystic fibrosis (CF). The present study examines endotoxin levels in bronchoalveolar lavage fluids of CF versus non-CF (N) control children, and correlates these with the inflammatory markers interleukin-8 and neutrophils. Fifty-five patients with CF and 56 patients without CF between the ages of 0.04 to 13.25 years were included. Infection, defined as a bacterial count above 50,000 cfu/ml, was present in 27 CF and 25 N patients. Endotoxin levels were not different between patients with and without CF (infected: 74.9 +/- 12.1 EU/ml versus 51.4 +/- 12.5 EU/ml, p = 0.16; noninfected: 5.9 +/- 4.8 EU/ml versus 11.1 +/- 4.3 EU/ml, p = 0.28). Endotoxin activity correlated to the number of gram-negative organisms in CF and N patients, and endotoxin activity per bacterial colony forming unit did not differ with various gram-negative species. Both interleukin-8 and neutrophils were positively correlated with endotoxin, but this slope was shifted toward higher levels of inflammation in CF patients. We conclude that it is unlikely that higher levels of endotoxin in the absence of viable bacteria explain the increased inflammatory response in CF.     

A lumbar hernia presenting as an obstructing lesion of the colon

A patient with a lumbar hernia of Petit, presenting as an obstructing lesion of the ascending colon and concomitant acute cholecystitis is described. The anatomy, cause, and surgical treatment of lumbar hernia are reviwed.