Congenital Diaphragmatic Hernia: A Rare Cause of Acute Abdomen

Abstract

Introduction: Congenital diaphragmatic hernias (CDH) in adults are usually asymptomatic. However, they can present with symptoms ranging from mild abdominal discomfort to symptoms of acute abdomen. Overall mortality rate is estimated to be 50%. Clinicians and surgeons need to be aware of this entity and should be cautious before dismissing them as insignificant. Case Report: An 87-year-old man presented to the emergency department with intractable nausea, vomiting, and intermittent upper abdominal pain for the past 2 days. Past medical history was significant for Parkinson’s disease and chronic kidney disease. At admission, the patient’s cardiac and respiratory examination were normal, the abdomen was soft, mildly distended with tenderness to deep palpation in the right upper quadrant. A rectal exam was guaiac-negative. Complete blood count, pancreatic enzymes, and a comprehensive metabolic panel were normal, other than a high serum creatinine consistent with a history of chronic kidney disease. A plain radiograph of the chest and abdomen revealed an elevated right hemidiaphragm with a gas distended structure in the upper abdomen. CT abdomen scout film revealed herniation of abdominal contents up into the lower chest through a possible defect in the diaphragm. The scan revealed swirling of mesentery with a proximal dilatation of the stomach. The hepatic flexure of the colon, distal stomach, and proximal duodenum were located in the right lower chest. The patient failed to respond to conservative management and the white cell count started rising along with a serum lactate. The patient was taken to the OR emergently and a Morgagni hernia with incarcerated transverse colon was discovered at laparotomy. The bowel contents were reduced and the hernia sac excised. Discussion: CDH was first described by Lazarus Riverius in 1679. Giovanni Battista Morgagni described the classical anterior diaphragmatic hernia. Three types of CDH are described in literature are Morgagni’s hernia, Bochdalek or the posterolateral hernia, and eventration of the diaphragm. CDH has an overall mortality of 50%. Treatment depends on the symptoms. It is important to be aware of strangulated Morgagni hernia as a rare cause of acute abdomen. Prompt diagnosis ensures a higher chance of successful repair. While these are considered to be benign, it is logical to expect that they will enlarge with time, and physicians should be cautious before dismissing Morgagni hernias in adults as clinically insignificant.