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Interesting Case Presentation

Interesting Case Presentation. Group 4. Personal Data. P.B. 71 year old/female Single DOA: December 13, 2009 CC: left lumbar pain. History of Present Illness. 20 years. Chest Xray: soft tissue mass superimposed by the left cardiac above the medial aspect of the left hemidiaphragm

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Interesting Case Presentation

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  1. Interesting Case Presentation Group 4

  2. Personal Data • P.B. • 71 year old/female • Single • DOA: December 13, 2009 • CC: left lumbar pain

  3. History of Present Illness 20 years • Chest Xray: soft tissue mass superimposed by the left cardiac above the medial aspect of the left hemidiaphragm • CT Scan: high position kidney herniating through the foramen of Bochdalek • (+) left sided chest heaviness, aggravated when lying supine • No consult 2 years

  4. History of Present Illness 1 year • (+) left lumbar pain • Consult • UTZ: questionable ectopic kidney • CT Scan: Bochdalek’s hernia (left) minimal pneumonitis inferior lingula, atheromatous aorta, thoracic spondylosis, diffuse osteoporosis, nephrolithiasis, left • Persistence of symptoms • Consult • CT Urogram: posterior left diaphragmatic hernia with intrathoracic left renal and colon, herniating, malrotated left kidney 3 months

  5. Review of Systems • No fever, weight loss, anorexia • No rash, pruritus • No headaches, dizziness • No visual disturbance, no colds and cough • No diarrhea, no constipation • No dysuria, hematuria • No polydipsia, polyphagia, polyuria, no heat and cold intolerance • No easy bruisability, no bleeding

  6. Past Medical / Surgical History • (+) Hypertension – maintained on Amlodipine 5mg/tab 1 tab OD • No asthma, allergy • No DM • No previous surgeries or confinements • No previous blood transfusion

  7. Family History • (+) HPN – mother • (+) lung disease – mother • (+) stroke – brother • (+) heart disease – brother • (+) goiter – mother • (-) DM, asthma, allergy, CA

  8. Personal History • Non smoker • Non alcoholic drinker • Denies illicit drug use

  9. OB and Menstrual History • M : 12 years old • I : 28 – 30 days, regular • D : 3 days • A : 2 ppd/moderately soaked • S : (+) dysmenorrhea • Menopause at 48 years old

  10. Physical Examination • Conscious, coherent, ambulatory, not in cardiorespiratory distress • BP 130/70 PR 92, regular RR 21, regular T 36.5 • Warm moist skin, no active dermatoses • Pink palpebral conjunctivae, anicteric sclerae, no palpable lymphadenopathy

  11. Physical Examination • Symmetrical chest expansion, no retractions, decreased tactile and vocal fremiti on left lower lung field, clear breath sounds • Adynamic precordium, AB 5th LICS MCL, no murmurs • Flabby abdomen, NABS, soft, no mass, no tenderness • Pulses full and equal, no cyanosis, no edema

  12. Salient Features • 71 y/o, Female • Left lumbar pain • Chest heaviness • No dyspnea • No nausea, vomiting • No abdominal pain, distention, tenderness • Bochdalek hernia • CT Scan • Urogram • decreased tactile and vocal fremiti on left lower lung field • No mediastinal deviation

  13. Differential diagnosis • Other congenital diaphragmatic hernias (Morgani’s) • Traumatic diaphragmatic hernia • Eventration

  14. Morgagni hernias • less common CDH • 5-10% of CDH cases • occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side

  15. Eventration of the diaphragm • anatomical or functional deficiency of part of the diaphragm, allowing abdominal contents to herniate into the chest • more commonly right sided, and affects the anterior portion of the hemidiaphragm

  16. Traumatic diaphragmatic hernia • Blunt and penetrating traumas cause most acquired diaphragmatic hernias • Left-sided rupture is more common than right-sided rupture, owing to hepatic protection and increased strength of the right hemidiaphragm

  17. Bochdalek hernias of the diaphragm • make up the majority of cases of CDH • posterolateral defects of the diaphragm • results in either failure in the development of the pleuroperitoneal folds or improper or absent migration of the diaphragmatic musculature

  18. Assessment • Bochdalek hernia

  19. Plans • CBC, Na, K • 12 L ECG • Chest X-ray • Exploratory laparotomy with possible thoracotomy

  20. Chest X-ray

  21. Chest Xray (12/13/09) • Both lungs are clear • Heart is not enlarged • Pulmonary vascularity is within normal limits • Left hemidiaphragm is markedly elevated • Gas-filled intestines are within the peritoneal cavity • There is no definite evidence of Bochdalek hernia • Left sulcus and posterior gutter are intact • There are moderate hypertrophic changes in the thoracic spine • Impression: ELEVATED LEFT HEMIDIAPHRAGM, SUGGESTIVE OF EVANTRATION

  22. Spirometry • Based on FEV1/FVC ratio, there is no obstructive ventilatory defect. • Flow volume loope is scooped out and the FEF 25-75 is low. Suggesting an early obstructive ventilatory defect. • Based on the 3% change in FEV1, there is poor response to bronchodilator. There seems to be no associated restrictive ventilatory defect based on normal FVC. • For verification we suggest a lung volume study.

  23. Coagulation Assay • PT 10.9s (10.3 -14.1) • NC 12.8 • PT ratio 0.9 • INR 0.9 • APTT 29.8 (27.0-45.4) • NC 36.1 s

  24. Urinalysis • Yellow • Clear • pH 6.0 • SG 1.020 • Alb neg • Sugar neg • RBC 0-2/hpf • Bac few

  25. ECG • Sinus arrythmia

  26. OR Done • Exploratory laparatomy with primary repair of Bochdalek hernia

  27. Bochdalek Hernia

  28. Primary Repair

  29. OR Findings • On opening, the spleen and left colon were mobilized, diaphragmatic hernia was appreciated at the posterior portion of the left hemidiaphragm. The left kidney and splenic flexure were seen herniated through the defect. All the other abdominal organs were grossly normal.

  30. Final Diagnosis • Bochdalek Hernia s/p primary repair of Bochdalek hernia

  31. Discussion

  32. Introduction • It was first described in 1848 by Bochdalek

  33. Embryology • Failure of the pleuroperitoneal canal to close at eight weeks gestation

  34. Embryology • Eighty percent occur on the left side • Bilateral, occasionally • The defect ranges from a small circular hole (Bochdalek hernia) to total absence of hemidiaphragm

  35. Embryology • Alter growth of the ipsilateral lung • Sometimes, it would alter the contralateral lung (when mediastinum shift to contralateral)

  36. Pathogenesis • Defective migration of muscle and nerve cell precursors to the diaphragm during formation • Diaphragm develops anteriorly as a septum between the heart and liver and then grows posteriorly

  37. Final closure is at the left Bochdalek foramen between 8 and 10 weeks GA • Bowel migrates from yolk sac to abdominal cavity at 10 weeks • If bowel arrive before the foramen closes then hernia can occur

  38. Epidemiology • Frequency in neonates: 1/7000 • Male/female ratio: 3:2 to 2:1 • Very uncommon in adult • 1992 – 100 cases reported in the literature • Growing use of abdominal CT, increase detection in asymptomatic individuals Luis Bujanda etc 2001~

  39. incidence of 0.17% based on 13,138 abdominal CT reports we reviewed. • The mean age of the patients was 66.6 years. None of the patients were symptomatic. • Sixty-eight percent of the hernias were on the right side of the body, 18% were on the • left side, and 14% were bilateral. Seventy-three percent contained only fat or omentum, Prevalence of Incidental Bochdalek’s Hernia in a Large Adult Population Mullens Et al Presented at the annual meeting of the Radiological Society of North America, Chicago 2000

  40. Bochdalek Hernia • Adult Bochdalek hernias are more frequently in women patients (77%) than in men. • Contents • 73% intraabdominal fat or omentum only • 27% had solid or enteric organ involvement • stomach, liver, spleen (33%), pancreas, or kidney (50%) Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR 2001;177: 363–6.

  41. In adults, most Bochdalek’s hernias are likely to be asymptomatic. Hines GL, Romero C. Congenital diaphragmatic hernia in the adult. Int Surg 1983;68:349–351 • Previously unrecognized Bochdalek hernia in the adult patient is often diagnosed incidentally to other problems.

  42. The most common presentation is left-sided abdominal and chest pain, associated with difficult breathing and intestitial obstruction. Thomas S, Kapur B. Adult Bochdalek hernia: clinical features, management and results of treatment.Jap J Surg 1991; 21(1): 114–119. • Sometimes, only gastrointestinal symptoms, caused mainly by obstruction of abdominal viscera. Steenhuis L.H., R.T.O. Tjon A Tham, F.W.J.M. Smeenk. Bochdalek hernia: a rare cause of pleural empyema. Eur Respir J, 1994, 7, 204–206

  43. Image examination • Chest x-ray (NG tube insertion) • Plain abdomen • Barium enema study • Upper GI barium study • Abdominal CT • Most accurate, • Can also detect associated anomalies • Abdominal MRI Shin MS, Mulligan SA, Baxley WA, Ho KJ. Bochdalek hernia of diaphragm in the adult. Diagnosis by computed tomography. Chest 1987;92:1098-1101

  44. Small, asymptomatic Bochdalek hernia does not require surgical intervention. Shin M S, S A Mulligan, W A Baxley and K J Ho. Diagnosis by computed tomography. Bochdalek hernia of diaphragm in the adult. Chest 1987;92;1098-1101

  45. Once diagnosed, the reductionof abdominal viscera in the abdominal cavity is mandatory due to the risk of life threatening complications. Kocakusak A, Arikan S, Senturk O, Yucel AF. Bochdalek’s hernia in an adult with colon necrosis. Hernia 2005;9:284–7.

  46. As soon as the diagnosis is made, operative repair should be carried out - even if there are no symptoms - because of the severe complications that large hernias can give, such as strangulation of hernial contents. L.H. Steenhuis, R.T.O. Tjon A Tham, F.W.J.M. Smeenk. Bochdalek hernia: a rare cause of pleural empyema. Eur Respir J, 1994, 7, 204–206

  47. Management • Aim: Reducing the viscera and sealing the diaphragmatic defect • Surgical repair is the most logical management • Laparotomy • Thoracotomy • Laparoscopy • Thoracoscopy • Or combinations

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