An Unusual Presentation of an Adult with Diffuse Abdominal Pain Related to Congenital Diaphragmatic Hepatic Eventration

Abstract

This case report identifies a uncommon presentation of a congenital diaphragmatic hepatic eventration in a middle aged female adult with an acute onset of diffuse abdominal pain. This case highlights a significant congenital event which is not commonly found as an adult. However, this case is interesting, as many clinicians may be puzzled over the radiologic presence, leading to numerable diagnostic studies and unnecessary consultations. A 43 year old Hispanic female with history of hypertension, diabetes and dyslipidemia presented to ER with complaint of diffuse abdominal pain, all quadrants of abdomen with no guarding or rigidity, normal bowel sounds. Routine labs showed no leukocytosis, normal metabolic panel except an elevated Cr of 1.7. CT Abdomen was done without any contrast in light of acute kidney injury, which showed a soft tissue mass at right lung base measuring 4.4 cm in diameter. Thought to be part of the hepatic dome pushing the diaphragm to the lung base versus, albeit less likely, a pulmonary mass, a CT with contrast was recommended. The patient was given symptomatic treatment in ER and was discharged with outpatient follow up. After her kidney function returned back to baseline CT abdomen with contrast showed focal eventration of the right hemidiaphragm with liver tissue extending through the eventration and no other suspicious mass. The patient was seen in GI clinic with impression of likely congenital anomaly. The patient was completely asymptomatic at that time and was conservatively managed with regular follow up. Congenital diaphragmatic eventration has been frequently cited in literature as a common condition in infancy, requiring urgent care and observation. However is a rare anomaly found in an adult. Eventation of the diaphragm is defined anatomically by thinning of the diaphragmatic tissue, characterized by the cephalic displacement an intact diaphragm. This entity is frequently asymptomatic and initially detected by chest x-ray. Adults can occasionally complain of progressive dyspnea, chest pain, abdominal discomfort, nausea/vomiting, heartburn. A differential must still be considered, including; diaphragmatic hernia, paraesophageal hernia, hiatus hernia, bronchogenic cyst, teratoma, cardiac sarcoma, lymphosarcoma, schwannoma, or metastatic tumor. Asymptomatic patients are usually managed with surveillance, and if persistently symptomatic managed with plication of the diaphragm with thoracotomy.2340_A Figure 1. Chest CT with IV Contrast- Sagittal view with hepatic eventration extending into thoracic cavity.2340_B Figure 2. Chest CT with IV Contrast- Coronal view with hepatic eventration extending into thoracic cavity.