The use of umbilical venography for the diagnosis of congenital right-sided diaphragmatic hernia.

Abstract

Accurate roentgenographic diagnosis L. of a large hernia through the foramen of Bochdalek in the newborn is imperative since prompt surgical treatment is usually needed to prevent death due to severe respiratory embarrassment (1). Even though 83 per cent of hernias occur on the left side (2), it is the massive intrathoracic herniation of the liver through a congenital right-sided diaphragmatic opening that most often gives rise to errors in diagnosis on chest plain films. A roentgenographic picture may be puzzling, with the opacified area being mistaken for pulmonary consolidation, pleural fluid, or an intrathoracic neoplasm, rather than recognized as a congenital diaphragmatic hernia (3). With the introduction of technics for catheterizing the umbilical vessels, an unusual opportunity has arisen to make possible the definitive diagnosis of congenital right-sided diaphragmatic herniation by visualizing the viscera involved. Angiography via the umbilical vessels has been shown to be safe and simple, virtually free of complications (4–8). The following case is the first report of the use of umbilical vein angiography for the diagnosis of congenital diaphragmatic hernia. Case Report Baby boy T. was noted to be moderately dyspneic, although acyanotic, shortly after birth. Very poor breath sounds were heard on the right side of the chest posteriorly, without adventitial sounds being detected. No. 5-French Argyle polyvinyl radiopaque feeding catheters were placed in both umbilical artery and umbilical vein in order to monitor blood gases and to supply nutriments. Some impairment in respiratory exchange was manifested by a p02 of 53, a pC02 of 42.5, and a pH of 7.31 in arterial blood. A chest film demonstrated virtually total opacification of the posterior aspect of the lower half of the right hemithorax. Just below this density, several loops of air-filled bowel were seen. The catheter in the umbilical vein was deviated more to the right at the level of the lower dorsal and upper lumbar vertebral bodies than is usual (Fig. 1). The findings were felt to be due to herniation of a large portion of the liver through the foramen of Boch-dalek into the right hemithorax. In order to make a definitive diagnosis, umbilical venography was performed via the feeding catheter. Under image-intensification fluoroscopic control, the tip of the catheter was placed just proximal to the ductus venosus, and 7 cc of Renografin 60 was slowly injected by hand into the catheter. Spot-films were obtained in both the frontal and the lateral projections. The resulting opacification of the liver revealed that the right lobe had herniated into the right hemithorax (Fig. 2). A follow-up pyelogram showed the kidneys in normal position. Surgical repair via a thoracoabdominal incision confirmed the radiologic findings. The patient made a satisfactory postoperative recovery.