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Incarcerated diaphragmatic hernia presenting as colonic obstruction.

Shogan PJS - MedPix (2008)

View Article: MedPix Image - MedPix Case

Affiliation: Uniformed Services University

ABSTRACT

Diagnosis: Incarcerated diaphragmatic hernia presenting as colonic obstruction.

History: 2 yo male presented to the Emergency Department with abdominal pain. Past medical history is significant for GERD, and difficulty with regular stooling. At 6 months of age, patient underwent a Nissen Fundoplication without complication.

Findings: Acute abdominal series demonstrates on the frontal chest radiograph a pleural effusion possibly with consolidation in the left lung field, with an ovoid collection of gas, and contralateral displacement of the mediastinal structures. The upright frontal radiograph of the abdomen demonstrates colonic air fluid levels in the bilateral lower abdomen. There is no evidence of free air. The supine frontal radiograph of the abdomen demonstrates dilated loops of colon. The admission chest radiograph demonstrates complete opacification of the left hemithorax, contralateral shift of the mediastinum, and colonic dilatation. Left lateral decubitus radiograph demonstrates opacification of the left hemithorax, with air fluid levels within a dilated loop of large instestine. Upon closer examination, there are ovoid gas collections at the left hemidiaphragm level. Sonographic evaluation of the left hemithorax obtained several hours after admission demonstrates what appears to be a large complex multiloculated pleural effusion, with diffusely consolidated lung with diffuse heterogeneous echotexture. Frontal radiograph of the abdomen obtained 1 day after admission demonstrates persistent dilatation of the ascending and transverse colon, with gas present in nondilated bowel in the left abdomen. Fluroscopic image of a Cysto-conray water soluble enema demonstrates prompt filling of the distal colon to the level of the splenic flexure, where it abruptly terminates in a beaked appearance. The transverse colon proximal to the site of obstruction is dilated. Intraoperative photographs demonstrate incarcerated bowel within a diaphragmatic hernia, with strangulated omentum. The bowel was found to be viable and was reduced into the abdomen. The diaphragmatic defect was closed. Post-operative frontal chest radiograph demonstrates the presence of a ET tube, enteric tube, and left sided thoracostomy tube. The bowel is decompressed, and there has been interval improvement in the opacified left hemithorax.

Ddx: Necrotizing pneumonia with associated colonic obstruction. Incarcerated diaphragmatic hernia with colonic obstruction.

Dxhow: Exploratory laporatomy.

Exam: Initial laboratory results were WBC of 10.6 and hematocrit of 27.4%.

No MeSH data available.


Intraoperative photograph demonstrates incarcerated bowel within a diaphragmatic hernia.
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MPX1161_synpic40035: Intraoperative photograph demonstrates incarcerated bowel within a diaphragmatic hernia.


Incarcerated diaphragmatic hernia presenting as colonic obstruction.

Shogan PJS - MedPix (2008)

Intraoperative photograph demonstrates incarcerated bowel within a diaphragmatic hernia.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=MPX1161&req=5

MPX1161_synpic40035: Intraoperative photograph demonstrates incarcerated bowel within a diaphragmatic hernia.

View Article: MedPix Image - MedPix Case

Affiliation: Uniformed Services University

ABSTRACT

Diagnosis: Incarcerated diaphragmatic hernia presenting as colonic obstruction.

History: 2 yo male presented to the Emergency Department with abdominal pain. Past medical history is significant for GERD, and difficulty with regular stooling. At 6 months of age, patient underwent a Nissen Fundoplication without complication.

Findings: Acute abdominal series demonstrates on the frontal chest radiograph a pleural effusion possibly with consolidation in the left lung field, with an ovoid collection of gas, and contralateral displacement of the mediastinal structures. The upright frontal radiograph of the abdomen demonstrates colonic air fluid levels in the bilateral lower abdomen. There is no evidence of free air. The supine frontal radiograph of the abdomen demonstrates dilated loops of colon. The admission chest radiograph demonstrates complete opacification of the left hemithorax, contralateral shift of the mediastinum, and colonic dilatation. Left lateral decubitus radiograph demonstrates opacification of the left hemithorax, with air fluid levels within a dilated loop of large instestine. Upon closer examination, there are ovoid gas collections at the left hemidiaphragm level. Sonographic evaluation of the left hemithorax obtained several hours after admission demonstrates what appears to be a large complex multiloculated pleural effusion, with diffusely consolidated lung with diffuse heterogeneous echotexture. Frontal radiograph of the abdomen obtained 1 day after admission demonstrates persistent dilatation of the ascending and transverse colon, with gas present in nondilated bowel in the left abdomen. Fluroscopic image of a Cysto-conray water soluble enema demonstrates prompt filling of the distal colon to the level of the splenic flexure, where it abruptly terminates in a beaked appearance. The transverse colon proximal to the site of obstruction is dilated. Intraoperative photographs demonstrate incarcerated bowel within a diaphragmatic hernia, with strangulated omentum. The bowel was found to be viable and was reduced into the abdomen. The diaphragmatic defect was closed. Post-operative frontal chest radiograph demonstrates the presence of a ET tube, enteric tube, and left sided thoracostomy tube. The bowel is decompressed, and there has been interval improvement in the opacified left hemithorax.

Ddx: Necrotizing pneumonia with associated colonic obstruction. Incarcerated diaphragmatic hernia with colonic obstruction.

Dxhow: Exploratory laporatomy.

Exam: Initial laboratory results were WBC of 10.6 and hematocrit of 27.4%.

No MeSH data available.