Unusual Bochdalek hernia in puerperium

The authors present an unusual case of a true left-sided posterolateral (Bochdalek) hernia containing stomach, transverse colon and spleen within a hernial sac in a 25-year-old female patient. They presume this voluminous herniation took place due to a rupture of congenitally preformed hernial ostium on account of increased intraabdominal pressure during repeated pregnancy. They describe an effective surgical transabdominal laparoscopic treatment.     

Bochdalek hernia in adults. Apropos of a case in the right side

Posterolateral diaphragmatic hernia (Bochdalek's hernia) is an infrequent finding in adult patients. Most of them are asymptomatic. Symptomatic cases present with digestive symptoms. Sometimes the clinical picture is related to the associated congenital malformations and not to the hernia itself. It is more common on the left side and in most of the cases it lacks of hernia sac. Simple radiologic study is the clue for the diagnosis. A case of Bochdalek's hernia in a 85 year-old patient is presented.     

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 case of bilateral Bochdalek hernia in an adult]

A 71-year-old male was found to have bilateral posteromedial masses on routine roentgenogram during admission for treatment of traffic accident related injuries. These masses were initially considered to be posterior mediastinal tumors, however, CT scan demonstrated a left diaphragmatic defect and the adipose nature of the bilateral masses (CT number: left -29, right -132). MRI also demonstrated a large amount of fat accumulation in the abdomen. CT scan and MRI are therefore very useful for the diagnosis of Bochdalek hernia in adults.     

An adult case of Bochdalek hernia complicated with hemothorax

A 53-year-old female with mild shock due to vomiting and abdominal pain visited the emergency room of our hospital. Chest X-ray on admission showed a large amount of left pleural effusion. Thoracentesis revealed hemorrhagic pleural effusion. An upper gastrointestinal series showed interruption of the upper gastric body, but the anal side was not visualized. Contrast X-ray examination of the thoracic cavity via the drainage tube demonstrated intrathoracic herniation through the diaphragm. These findings suggested gastric impaction in the foramen of Bochdalek, and thoracotomy was immediately performed. A black-colored stomach and greater omentum, suggesting necrotic changes, were observed in the thoracic cavity, and there was bleeding from the greater omentum. Resection of the necrotic organs and closure of the hernial orifice were followed by good recovery.