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Daniel Horton, HMS IIIGillian Lieberman, MD
An Unusual Presentation of Diaphragmatic Hernia
Daniel B. Horton Harvard Medical School Year III
Gillian Lieberman, MD
January 2007
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: Clinical Presentation, Nov. 2004
•
52 year old woman presents with new nonproductive cough & dyspnea
•
PMH: Obesity, recurrent bronchitis•
ROS: No GI or GU complaints, no history of prior trauma or major surgery
•
PE: Decreased breath sounds at left lung base
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: Chest Radiograph, 11/26/04
ElevatedElevatedhemidiaphragmhemidiaphragm
Bowel gasBowel gas
ShiftedShiftedmediastinummediastinum
PACS, BIDMC
Bowel gasBowel gas
Crowded vessels?Crowded vessels?AtelectasisAtelectasis??
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Daniel Horton, HMS IIIGillian Lieberman, MD
DDx: Elevated Hemidiaphragm•
Lung conditions “pulling”
up diaphragm–
Atelectasis–
Prior lobectomy–
Pulmonary disease, e.g., pulmonary fibrosis
•
Abdominal (and other) conditions “pushing”
up diaphragm–
Organ enlargement, e.g., splenomegaly, distended stomach–
Inflammatory or infectious process, e.g., subphrenic
abscess–
(Subpulmonic
effusion-“pushes”
up lung from above diaphragm; not a truly elevated diaphragm)
•
Diaphragmatic defects–
Eventration-muscular defect causing weakness–
Paralysis-elevation and paradoxical movement–
(Hernia-not a truly elevated diaphragm)
PACS, BIDMC
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Daniel Horton, HMS IIIGillian Lieberman, MD
In fact, after a recent colonoscopy was limited by a redundant colon, patient
LG underwent virtual CT colonoscopy which revealed her diagnosis…
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: Virtual Colonoscopy Coronal CT, 8/3/04
PACS, BIDMC
SCOUTVIEW
Herniated bowelHerniated bowel
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: Virtual Colonoscopy Axial CT, 8/3/04
AscAscAortaAorta
Main Main PulmPulm
ArtArt
FatFatSOFT TISSUE
WINDOW ColonColon
AtelectasisAtelectasis
LUNGWINDOW
Courtesy of Dr. Khasgiwala
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Daniel Horton, HMS IIIGillian Lieberman, MD
Amazingly, when this large diaphragmatic hernia was first diagnosed in August 2004,
at age 52, LG was asymptomatic.
Her respiratory symptoms would only begin several months later.
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: Hospital Admission 12/28/04-1/7/05
•
From November to December 2004, LG continued to have progressive dyspnea and cough, increasingly productive of greenish sputum, and intermittent fevers
•
Outpatient CT on 12/28/04 demonstrated pneumonia with LUL abscess and pleural effusion
•
Patient was admitted to BIDMC later that day for further work-up and management
•
CT-guided abscess drainage was performed on 1/1/05
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: CT-Guided Abscess Drainage, 1/1/05
PigtailPigtailCatheterCatheter
PACS, BIDMC
NON-CONTRASTAXIAL CT
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: Axial Contrast CT, 1/3/05
Abscess w/ catheterAbscess w/ catheter
EmpyemaEmpyema
KidneyKidney
CT, 5 months ago
Courtesy of Dr. Khasgiwala
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: Coronal and Sagittal Contrast CT, 1/3/05
AbscessAbscessw/ catheterw/ catheter
EmpyemaEmpyema
CORONAL SAGITTAL
KidneyKidney
ColonColon
Courtesy of Dr. Khasgiwala
ColonColonDiaphragmDiaphragm
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: Hospital Admission 12/28/04-1/7/05
•
Diagnosis–
Bochdalek
diaphragmatic hernia
–
Streptococcus milleri
pneumonia complicated by LUL abscess and multiloculated
empyema
•
Treatment–
Abscess drainage
–
Antibiotics (CTX)•
Elective diaphragmatic repair was deferred pending resolution of infection
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Daniel Horton, HMS IIIGillian Lieberman, MD
Let’s put our patient’s unusual presentation into a broader context
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Daniel Horton, HMS IIIGillian Lieberman, MD
Diaphragmatic Hernias (DH): Classification
•
Congenital–
Bochdalek
–
Morgagni–
Hiatus
•
Idiopathic•
Acquired–
Traumatic
–
Iatrogenic
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Daniel Horton, HMS IIIGillian Lieberman, MD
Diaphragmatic Hernias (DH): Classification
•
Congenital–
Bochdalek
–
Morgagni
–
Hiatus
•
Idiopathic •
Acquired–
Traumatic
–
Iatrogenic
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Daniel Horton, HMS IIIGillian Lieberman, MD
Development of Diaphragm
Week 14
Adapted from Sadler, Langman’s
Medical Embryology, 9th Ed, 218.
Week 9Week 7
GESTATIONAL AGE
Pleuroperitoneal
membrane
Septum Transversum
Pleuroperitonealcanal
Body wall muscle ingrowth
IVCEs
Ao
Defect leads toDefect leads toBochdalekBochdalek
herniahernia
Anterior defect leadsAnterior defect leadsto to MorgagniMorgagni
herniahernia
Defect leadsDefect leadsto hiatus herniato hiatus hernia
Dorsal mesentery of esophagus
Pleuroperitonealfold
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Daniel Horton, HMS IIIGillian Lieberman, MD
Mature Diaphragm Diagram
Esophageal HiatusEsophageal Hiatus
MorgagniMorgagni
foraminaforamina
BochdalekBochdalek
foraminaforamina
INFERIOR SURFACE
R L
Moore and Agur, Essential Clinical Anatomy, 2nd
Ed,
188.
IVC
Aorta
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Daniel Horton, HMS IIIGillian Lieberman, MD
Congenital DH: Bochdalek•
Posterolateral
defect through Bochdalek
foramen
•
Most common congenital diaphragmatic hernia (1:2200 live births)
Moore and Agur, Essential Clinical Anatomy, 2nd
Ed,
188. Sadler, Langman’s
Medical Embryology, 9th Ed, 220.
•
L>R>>bilateral–
L: bowel, stomach, fat,
spleen, kidney–
R: liver, fat,
kidney•
Neonates with large hernias often present with respiratory distressdue to poor fetal lung development
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Daniel Horton, HMS IIIGillian Lieberman, MD
Congenital DH: Morgagni•
Anteromedial
defect through Morgagni
foramen
•
Rare (1:1,000,000 live births)•
R>L
•
Often small, containing only fat, and asymptomatic
Moore and Agur, Essential Clinical Anatomy, 2nd
Ed,
188.
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Daniel Horton, HMS IIIGillian Lieberman, MD
Congenital DH: Hiatus•
Herniation
of stomach through esophageal hiatus
•
Overall rare in children•
Of the three different subtypes of hiatus hernia (see below), paraesophageal
is most common congenital form
–
Congenital paraesophageal
hernias not often associated with complications (e.g., obstruction), as in adults
Moore and Agur, Essential Clinical Anatomy, 2nd
Ed,
188. http://coastalsurgery.com/news-hiatal_hernias.htm
Type I “Sliding”
Type IIParaesophageal
Type IIIMixed
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Daniel Horton, HMS IIIGillian Lieberman, MD
Imaging Pediatric
DH
•
Prenatal ultrasound (US)•
Neonatal radiographs–
Contrast studies may help
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Daniel Horton, HMS IIIGillian Lieberman, MD
Companion Patient #1 Prenatal US: Congenital DH
Hedrick & Adzick, UpToDate, 2006.
DiaphragmDiaphragm
StomachStomach
LiverLiver
DiaphragmDiaphragm
Findings suggestive of DH:•Abdominal organs in thorax•Contralateral
mediastinal
shift•Small abdominal circumference
HeadHeadHeadHead
SAGITTAL HIGH-RESOLUTION FETAL ULTRASOUND
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Daniel Horton, HMS IIIGillian Lieberman, MD
Prenatal US: Congenital DH
•
Advantages–
Routinely performed
–
Safe for woman and fetus –
Early diagnosis
•
Search for other associated anomalies (prenatal karyotype, echo)•
Opportunity for prenatal intervention (e.g., fetal tracheal occlusion)•
Plan for delivery and critical postnatal care at tertiary hospital•
Prepare parents psychologically•
Disadvantages–
User dependent
–
Limited resolution–
May not detect smaller abnormalities
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Daniel Horton, HMS IIIGillian Lieberman, MD
Courtesy of Dr. Khasgiwala
ShiftedShiftedmediastinummediastinum
BowelBowel
CompressedCompressedLungLung
ECG leadsECG leads
ET TubeET Tube
AP
DDx:Bochdalek
diaphragmatichernia
Congenital cystic adenomatoidmalformation
Cystic pulmonary interstitialemphysema
Companion Patient #2 Neonatal Radiograph: Congenital Bochdalek
DH
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Daniel Horton, HMS IIIGillian Lieberman, MD
Companion Patient #3 Neonatal Radiograph: Congenital Morgagni
DH
BowelBowel
BowelBowelMediastinumMediastinum
CompressedCompressedLungLung
AP Lateral
Courtesy of Dr. Khasgiwala
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Daniel Horton, HMS IIIGillian Lieberman, MD
Companion Patient #4 Neonatal Radiograph: Congenital Hiatus DH
AP
Karpelowsky, Wieselthaler, Rode, J Pediatr
Surg
2006 41:1588-93.
Lateral
Cystic mass inCystic mass inposterior posterior mediastinummediastinum
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Daniel Horton, HMS IIIGillian Lieberman, MD
Companion Patient #5 Neonatal Barium Study: Congenital Hiatus DH
Esophageal hiatusEsophageal hiatus
Gastric Gastric fundusfundus
EsophagusEsophagusBarium study performed to distinguish from other posterior mediastinal
cystic masses, such as:
•Epiphrenic
diverticulum•Pulmonary cyst•Cystic tumor
Karpelowsky, Wieselthaler, Rode, J Pediatr
Surg
2006 41:1588-93.
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Daniel Horton, HMS IIIGillian Lieberman, MD
Neonatal Radiograph: Congenital DH•
Advantages–
Widely available and cheap
–
Demonstrates anatomy–
Contrast studies (e.g., barium) may be used for confirmation
–
Can track progress and complications of interventions (e.g., lines, catheters, pulmonary disease, pre/post-op)
•
Disadvantages–
Exposes child to radiation
–
Limits to identifying involved structures–
If small hernias are missed by US and asymptomatic, they will not be detected
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Daniel Horton, HMS IIIGillian Lieberman, MD
And now let’s turn to other presentations of diaphragmatic hernias in adults,
which sometimes recapitulate (if not represent) congenital phenotypes
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Daniel Horton, HMS IIIGillian Lieberman, MD
Diaphragmatic Hernias (DH): Classification
•
Congenital–
Bochdalek
–
Morgagni–
Hiatus
•
Idiopathic
•
Acquired–
Traumatic
–
Iatrogenic
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Daniel Horton, HMS IIIGillian Lieberman, MD
Imaging Adult
DH
•
Radiographs ± contrast•
Cross-sectional studies: CT, MR–
Characterize anatomy of hernia
–
Identify potential complications (e.g., respiratory, GI)–
Directly identify diaphragmatic defect
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Daniel Horton, HMS IIIGillian Lieberman, MD
Idiopathic DH: Hiatus Hernias
•
Most common diaphragmatic hernia overall, usually of unclear etiology
http://coastalsurgery.com/news-hiatal_hernias.htm
Type I “Sliding”
Type IIParaesophageal
Type IIIMixed
–
Type I (sliding) predominates•
About half present with GERD
•
Usually medically managed
–
Other types (e.g., paraesophageal) less common
•
May present with obstruction due to volvulus
•
Surgical repair is indicated, even if incidental and asymptomatic
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Daniel Horton, HMS IIIGillian Lieberman, MD
Kahrilas, Pandolfino. GI Motility online 2006 | doi:10.1038/gimo48
Gastric Gastric rugalrugal
foldsfolds
EsophagusEsophagus
A ringA ring
Esophageal hiatusEsophageal hiatus
Companion Patient #6 Barium Study: Type I Hiatus Hernia
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Daniel Horton, HMS IIIGillian Lieberman, MD
Idiopathic DH: Other Types
•
There are multiple case reports of Bochdalek and Morgagni
hernias of unclear etiology in
adults, which are diagnosed incidentally or because of symptoms
•
A retrospective review of 13,138 abdominal CT reports for adults patients at a large urban hospital identified incidental Bochdalek
hernias
in 0.17%, of which 27% involved solid or enteric organs
Megremis
et al., J Clin
Ultrasound
2005;33:412-7.
Mullins et al., AJR
2001;177:363-366.
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Daniel Horton, HMS IIIGillian Lieberman, MD
Companion Patient #7 Radiographs and CT: Morgagni
DH in Asymptomatic 64yo Female
Schubert H and Haage
P. N Engl
J Med 2004;351:e12
PA
Lateral
PARASAGITTAL
CONTRAST CTRADIOGRAPH
Arrow=R anterior cardiophrenic
mass
Asterisk=herniated mesenteric fatArrowheads=anteromedial
diaphragmatic defect
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Daniel Horton, HMS IIIGillian Lieberman, MD
Acquired DH: Trauma
•
Penetrating trauma–
Direct injury to diaphragm causes rupture
–
Often undergo quick surgical repair
•
Blunt trauma–
Impact may lead to direct or indirect injury of diaphragm
•
Increased abdominal pressure may push abdominal structures through a weakened diaphragm
–
Many hernias are missed early, and patients can present late with respiratory illness or GI complication (e.g., obstruction)
–
L>R>bilateral (R-sided protection of liver)
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Daniel Horton, HMS IIIGillian Lieberman, MD
Companion Patient #8 Radiograph & Axial CT: Traumatic DH in 47yo Male s/p MVAPA CHEST RADIOGRAPH (CONED DOWN)
RibRibfracturesfractures
BowelBowel
EffusionEffusion
AXIAL CONTRAST CT
Eren, Kantarcı, Okur. Clinical Radiology 2006; 61:467-477.
DiaphragmDiaphragmdefectdefect
RibRibfracturefractureHemothoraxHemothorax
BowelBowel
FatFat
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Daniel Horton, HMS IIIGillian Lieberman, MD
Acquired
DH: Iatrogenesis
•
Thoraco-abdominal surgeries, esp. esophago- gastrectomy
(e.g., for esophageal cancer), may
lead to acquired DH–
Similar presentation and complications to traumatic hernias
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Daniel Horton, HMS IIIGillian Lieberman, MD
Diaphragmatic Hernia Repair
•
Medical management suffices for most sliding hiatus hernias and small idiopathic hernias
•
Surgical repair is indicated for most pediatric, acquired, and otherwise symptomatic adult DH
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Daniel Horton, HMS IIIGillian Lieberman, MD
So what finally happened with our patient?
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Daniel Horton, HMS IIIGillian Lieberman, MD
Patient LG: Clinical Course
•
After resolution of infection with many months of antibiotic therapy (CTX followed by Levo/Clinda), LG underwent successful surgical repair of the diaphragm in July 2005
•
Surgery revealed:–
extensive adhesions from previous empyema
–
8 x 5 cm defect in the posterolateral
diaphragm consistent with “a congenital Bochdalek
type hernia”
(per operative report)
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Daniel Horton, HMS IIIGillian Lieberman, MD
PRE-OP7/6/05
POST-OP9/8/05
PleuralPleuraleffusioneffusion
LinearLinearatelectasisatelectasis
PACS, BIDMC
PA
Lateral
Patient LG: Chest Radiograph Before and After Diaphragm Repair
Key findings:•Repaired diaphragm•Normal mediastinum•Minor post-op changes
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Daniel Horton, HMS IIIGillian Lieberman, MD
Summary•
Congenital diaphragmatic hernias can be classified as Bochdalek, Morgagni, or hiatus types
•
Prenatal imaging followed by neonatal radiographs represent the best tests to identify congenital diaphragmatic hernias and track the children’s clinical course
•
For adults with suspected idiopathic or acquired diaphragmatic hernias, radiographs ± contrast and cross-sectional imaging can best characterize the defects and their associated complications
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Daniel Horton, HMS IIIGillian Lieberman, MD
Acknowledgments
•
Gillian Lieberman, MD•
Vaibhav
Khasgiwala, MD
•
David Roberts, MD•
Molly Collins
•
Alex Herrera•
Pamela Lepkowski
•
Larry Barbaras, webmaster
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Daniel Horton, HMS IIIGillian Lieberman, MD
References•
Eren
S, Kantarcı
M, and Okur
A. Imaging of diaphragmatic rupture after trauma. Clinical Radiology 2006; 61:467-477.
•
Hedrick HL and Adzick
NS. Congenital diaphragmatic hernia: Prenatal diagnosis and management. UpToDate
2006.•
Juhl
JH. Ch. 31
Diseases of the pleura, mediastinum, and diaphragm. Essentials of Radiologic Imaging,
6th Ed. Juhl
JH, Crummy AB, Eds. 1993; Lippincott Company, Philadelphia.•
Kahrilas
PJ. Hiatus Hernia. UpToDate
2005.•
Kahrilas
PJ and Pandolfino
JE. Hiatus hernia. GI Motility online 2006; doi:10.1038/gimo48.•
Karpelowsky
JS, Wieselthaler
N, and Rode H. Primary paraesophageal
hernia in children. J Pediatr
Surg
2006;41:1588-93.•
Mei-Zahav
M, Solomon M, Trachsel
D, and Langer JC. Bochdalek
diaphragmatic hernia: not only a neonatal disease. Arch Dis
Child
2003;88:532-5.•
Megremis
SD, Segkos
NI, Gavridakis
GP, Mattheakis
MG, Kehayas
EG, Triantafyllou
LB, Sfakianaki
EE, and Chalkiadakis
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