Right-sided diaphragmatic eventration with gastric volvulus and abnormal rotation of liver

Abstract

Background: Diaphragmatic eventration is permanent elevation of an immobile hemidiaphragm. It is commonly described on the left side and very rarely on the right side. It usually is associated with acute gastric volvulus with strangulation. Sometimes it is complicated with malrotation of abdominal contents. Mesenteroaxial volvulus is usually primary, without an underlying diaphragmatic defect. Case Presentation: A 50-year-old male presented with occasional shortness of breath and intermittent abdominal pain for past four months. Chest examination revealed decreased movements on right side. Chest X-ray showed elevated right hemidiaphragm and minimal left sided mediastinal shift. Fluoroscopy revealed decreased movement of the right hemidiaphragm. Contrast enhanced CT scan of the chest and abdomen revealed that right hemidiaphragm was raised and reaching up to the level of horizontal fissure. Mild basal atelectasis was present in underlying lung parenchyma. There was herniation of liver with mild rotation, right kidney, hepatic flexure of colon, few jejunal loops, abdominal fat and few mesenteric vessels into the right thoracic cavity. Upper gastrointestinal contrast study revealed displacement of antrum above the gastroesophageal junction. A diagnosis of eventration of right diaphragm with abnormal rotation of liver and mesenteroaxial gastric volvulus was made. Conclusion: The prompt diagnosis of right diaphragmatic eventration with mesenteroaxial gastric volvulus and abnormal rotation of liver is critical to avoid catastrophic complications of ischemia, perforation and strangulation as early management in such cases without gastric necrosis is associated with less postoperative morbidity and mortality.