Massive diaphragmatic herniation following orthotopic liver transplantation in an adult

Abstract

Four years after orthotopic liver transplantation wasperformed for cirrhosis due to chronic hepatitis C, a58-year-old woman presented with nausea and vomit-ing, abdominal pain, a feeling of fullness and tensionin the upper abdomen, fatigue, and a loss of 10 kg ofbody weight during the preceding 8 weeks. She hadfevers up to 38.5 C (101 F). Abdominal X-rays, ab-dominal and cardiac ultrasound examinations, andgastroscopy indicated no abnormalities. However, theresults of serum biochemical liver tests were as fol-lows: aspartate aminotransferase, 483 U/L (normallevel < 30 U/L); alanine aminotransferase, 200 U/L(normal level < 35 U/L); gamma-glutamyl transferase,742 U/L (normal level < 38 U/L); bilirubin, 2.36 mg/dL (normal range ¼ 0.1-1.2 mg/dL); alkaline phos-phatase, 161 U/L (normal range ¼ 35-105 U/L); andlactate dehydrogenase, 325 U/L (normal range ¼ 120-240 U/L). A liver biopsy sample exhibited changesthat suggested allograft rejection rather than a recur-rence of hepatitis C. In addition to baseline immuno-suppression with everolimus (trough level ¼ 4.8 ng/mL) and mycophenolate mofetil (trough level ¼ 1.1lg/mL), the patient received corticosteroids to treatallograft rejection. Although the serum biochemicalliver tests gradually improved, her symptoms did not.Subjective indices of the patient’s health and well-being did not correlate with objective findings. Theadministration of analgesics and antidepressants wasassociated with only minor improvements in hersymptoms. However, abdominal computed tomogra-phy revealed a large diaphragmatic herniation; itsdimensions were 15 cm 10 cm. The entire left he-patic lobe had shifted into the mediastinum (Fig. 1).Subsequent thoracic magnetic resonance imagingconfirmed the magnitude of the herniation. The infe-rior vena cava was severely compressed, and the rightventricle was displaced by the herniated liver.The herniation was closed completely during a com-bined thoracotomy-laparotomy procedure. Intraopera-tively, most of the liver was found to have herniatedinto the thorax (Fig. 2). The liver had displaced theright atrium and the right ventricle (Fig. 1). In addi-tion, the displaced liver tightly adhered to the entire