Left Sided Hydro-pneumothorax in a Operated Case of Left Diaphragmatic Hernia Repair: A Diagnostic Dilemma

Abstract

Diaphragmatic hernia in adults often presents with overlapping respiratory and abdominal symptoms. They may be simple diaphragmatic eventrations or undiagnosed Bochdalek's hernias or may even be of post traumatic variety. Diaphragmatic hernias may be asymptomatic, present only with respiratory symptoms, or may present with obstruction and strangulation of involved bowel loops with faeco-pneumothorax. The index case was operated for open diaphragmatic hernia repair six years back and admitted for breathlessness with absence of abdominal signs and symptoms. Patient subsequently developed hydro-pneumothorax during conservative management. Emergency laparotomy revealed a gastric ulcer which perforated into the left chest giving rise to hydro-pneumothorax. In present study we would like to report how this unusual presentation led to dilemma in diagnosis and surgical intervention thus increasing the morbidity and mortality of the patient at our institute.

Keywords: Bilious hydro pneumothorax; Gastric ulcer perforation; Recurrent diaphragmatic hernia.

[Table/Fig-1]:

Chest x-ray on admission showing elevated left hemi-diaphragm

[Table/Fig-2]:

Showing chest x-ray on day 3 of conservative treatment showing left sided hydro-pneumothorax

[Table/Fig-3]:

Showing axial cut sections of chest CT showing left sided hydro-pneumothorax with diaphragmatic hernia

[Table/Fig-4]:

Showing sagittal and coronal sections of chest CT showing left sided hydro-pneumothorax with diaphragmatic hernia

[Table/Fig-5]:

Showing immediate post-ICD x-ray chest showing adequate expansion of left lung

[Table/Fig-6]:

Showing repeat chest x-ray showing complete white out lung fields on left side

[Table/Fig-7]:

Showing diaphragmatic defect intraoperatively

[Table/Fig-8]:

Showing perforated ulcer on body of stomach intraoperatively.