A Rare Case of Partial Diaphragmatic Eventration with Hepatic Herniation

Abstract

A 43 year old Female with past history of hypertension, diabetes mellitus presented to the Emergency room with a chief complaint of left flank pain. Her physical examination was notable for left sided flank tenderness with no abdominal rigidity or guarding. Routine blood work showed normal complete blood count, with normal comprehensive metabolic profile. A chest xray showed a soft tissue mass at the right lung base. Further contrast Computed Tomography(CT) of the chest and abdomen showed an incidental soft tissue mass at right lung base that measured 4.4 cm in diameter representing a focal eventration of the right hemi-diaphragm with liver tissue extending through the eventration.(Fig 1,2).2343_A Figure 1. Arrow depicting hepatic herniation2343_B Figure 2. Coronal CT showing hepatic mass extending through diaphragamDiaphragmatic eventration was first recognized by Jean Louis Petit in 1774 and the term was coined by Beclard in 1916. It is defined anatomically by thinning of the diaphragmatic tissue, characterized by the cephalic displacement of all or a part of an intact diaphragm. While complete eventration in more common on left, partial eventration is seen majorly on the right side. Congenital diaphragmatic eventration has been frequently cited as common in infancy, requiring urgent care and observation but it is rarely seen in adults. Typically this entity is frequently asymptomatic but can rarely manifest as progressive dyspnea, chest pain, abdominal discomfort, nausea, vomiting, heartburn and recurrent pneumonia. Partial eventration are usually detected incidentally on chest x-ray as a smooth homogeneous mass in continuation with the diaphragm.Ultrasound may reveal more anatomical detail about the diaphragmatic integrity, specifically eventration content or other diaphragmatic pathologies.If a contrast CT scan is performed, hepatic or omental vascular enhancements are seen as hyper-dense areas. Other modalities such as fluoroscopy with sniff testing and Magnetic resonance imaging are done if the diagnosis is still in doubt. Once diagnosed asymptomatic patients are usually managed conservatively and diaphragmatic plication is done in symptomatic patient. Our patient's left sided pain was musculoskeletal and not related to the diaphragmatic eventration. Her pain resolved with analgesics and she has remained asymptomatic on follow up visits. In summary we present a rare case of partial diaphragmatic eventration with hepatic herniation. Our case highlights conservative management in asymptomatic patients with diaphragmatic eventration.