Triple Trouble: Colonic Obstruction by Sigmoid Volvulus in a Patient Affected by Ogilvie Syndrome and Giant Bochdalek Hernia

Filippo Montali,Federico Marchesi,Gerardo Palmieri,Renato Costi

doi:10.31487/j.scr.2020.05.12

Abstract

Bochdalek hernia is a congenital left diaphragmatic hernia (CDH), usually diagnosed in children following the onset of thoracic symptoms such as dyspnea or tachycardia. Ogilvie’s syndrome (or acute colonic pseudo-obstruction) may be due to several conditions, including neurologic diseases, neuroleptic therapy and systemic syndromes, and is characterized by massive colon dilation in the absence of mechanical obstruction or toxic mega-colon. Sigmoid volvulus, consisting of sigmoid rotation around its axis, is a relatively frequent cause of large bowel obstruction. The three simultaneous conditions in the same patient in an emergency setting are rare, leading to a challenging situation concerning diagnosis and management. Here, we report the case of a mentally disabled 59-year-old female presenting with colonic obstruction caused by sigmoid volvulus after several episodes of Ogilvie’s syndrome-related pseudo-occlusion, found to have a giant left-sided Bochdalek diaphragmatic hernia. The patient was treated by an emergency laparoscopic approach. Despite the resolution of the abdominal picture, the patient died on postoperative day 15 by respiratory failure.

Highlights

Bochdalek hernia (BH) is a congenital diaphragmatic hernia caused by the incomplete fusion of the posterolateral diaphragmatic foramina during the 9-10th week of pregnancy, resulting in abdominal organs displacement into the thorax [1, 2]
Most appropriate management of those three concomitant conditions, namely sigmoid volvulus complicated by colonic segmental necrosis, Ogilvie syndrome and massive Bochdalek hernia in an emergency setting
Typical sigmoid volvulus presentation is distal large bowel obstruction needing emergency management, but, rarely, its clinical presentation may be as a chronic recurrent abdominal pain [14]

Summary

Introduction

Bochdalek hernia (BH) is a congenital diaphragmatic hernia caused by the incomplete fusion of the posterolateral diaphragmatic foramina during the 9-10th week of pregnancy, resulting in abdominal organs displacement into the thorax [1, 2]. Small or large bowel migration through the diaphragm into thorax is the most frequent cause of intestinal obstruction in BH patients [4]. A 59-year-old female patient was admitted to the emergency room with colicky pain, dysphagia, constipation, and dyspnea. She was a long-time psychiatric hospital inpatient with severe schizophrenia and dementia on clozapine therapy already undergoing. X-rays showed diffuse colonic dilatation, both in the abdomen and the thorax, reaching the projection line of the left collarbone. CT-scan (Figure 1) showed a massive herniation of intra-abdominal organs into the left hemithorax through a large defect in the left posterior diaphragm, associated with diffuse colonic distension. The postoperative course was uneventful with bowel movement on POD 4, until POD 15, when the patient developed dyspnea, rapidly deteriorating to respiratory failure until death occurred 6 hours later

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Conclusion