AB132. SOH24AB_043. Acquired diaphragmatic hernia of unknown aetiology

Background: Diaphragmatic hernia is the protrusion of abdominal contents through a diaphragmatic defect into the thorax. These can be congenital or acquired. Acquired diaphragmatic hernia is usually preceded by trauma, either blunt or penetrating. Very rarely acquired diaphragmatic hernia can occur spontaneously.

Methods: A 43-year-old female presented to the emergency department with a four-day history of right chest pain radiating to the scapula, shortness of breath and absent breath sounds on the right lower lobe. Chest X-ray (CXR) showed an oval shaped focus of air in the right lower zone with mediastinal shift to the left and a large right sided pleural effusion. Computed tomography thorax, abdomen and pelvis (CT TAP) demonstrated a diaphragmatic hernia containing ischaemic colon and collapse of the right middle and lower lobes with a reactive pleural effusion. The patient had an unremarkable CXR one year earlier. There was no history of trauma (blunt or penetrating). Emergency laparotomy was performed and revealed an anterior right diaphragmatic hernia containing 15 cm ischaemic transverse colon. The diaphragmatic defect was repaired primarily. A transverse colectomy and primary anastomosis was performed and a right sided chest drain inserted.

Results: The patient was admitted to the intensive care unit for one day postoperatively. Her course was complicated by clostridium difficile infection and persistent pleural effusion. Chest drain was removed day 6 post-operatively and she was discharged home well.

Conclusions: Without trauma, acquired diaphragmatic hernias (especially right sided) are vanishingly rare and thus, early diagnosis and definitive surgical management is imperative to ensure good clinical outcome.

Keywords: Case report; diaphragmatic hernia; acute abdomen; spontaneous; strangulation