Medical image. Antero-lateral diaphragmatic hernia presenting in the sixth decade

ClinicalA 52-year-old male presented to our outpatient department with complaints of abdominal distension for 6 months and breathlessness on exertion for 3 months. The symptoms minimally interfered with his daily activities . To the best of his memory there was no past or recent history of trauma. He never had a chest X-ray imaged in the past.Although on examination he appeared comfortable he had dyspnoea after going up four flights of stairs. His vitals were stable. Respiratory system examination had features suggestive of left moderate pleural effusion. Examination of the abdomen was unremarkable. Chest X-ray PA view (Figure 1) showed homogenous opacity over the left lower zone with circumscribed internal air translucencies, a finding consistent with left lower lobe parenchymal pathology possibly cavities associated with para-pneumonic effusion. Figure 1. Chest X-ray PA view with homogenous opacity over the left lower zone with circumscribed internal air translucencies Since his primary symptom was abdominal distension, a CT-thorax with abdominal screening (Figures 2 and 3) was requested which showed a 4 cm 00d7 4 cm diaphragmatic defect in the antero-lateral region and a 1 cm 00d7 1 cm defect in the postero-lateral region of the left diaphragm with herniation of bowel loops into the thorax . The bowel loops could be visualised up to the level corresponding to tracheal bifurcation along with hypoplasia of left lower lobe (Figure 4). Figure 2. Lung window of CT-thorax showing the larger antero-lateral defect and smaller postero-lateral defect in the left diaphragm Figure 3. Lung window of CT-thorax showing the herniated bowel loops in the thorax Figure 4. Reconstructed film of CT-thorax showing the extent of bowel herniation into thorax He underwent surgical reduction of the abdominal contents which herniated through the anterolateral defect (no herniation were found through the posteriolateral defect) followed by closure of the anterolateral and posterolateral defect in the left diaphragm with a prolene mesh. Peritoneal covering observed over the diaphragmatic defect and lack of post-inflammatory features in the defect indicated the hernia to be of congenital nature. DiscussionDiaphragmatic hernia may be congenital or acquired. The incidence of congenital diaphragmatic hernia (CDH) range from 1:2000 to 1:5000 live births.1Bochdalek hernia(defect in the postero-lateral part of the diaphragm) and Morgagni hernia (defect in anterior part of diaphragm close to midline) account for more than 90% of congenital diaphragmatic hernias.2 Though CDH is often diagnosed in the antenatal or immediate postnatal period, about 10% of them can present later in life at an age from 32 days to 15 years.2 Reports of antero-lateral diaphragmatic hernia are rare.3,4 The prolonged asymptomatic period in our patient could possibly be due to minimal herniation of bowel loops into thorax earlier in life with a recent increase in herniation making him symptomatic. The age of our patient, asymptomatic status for 5 decades, and antero-lateral herniation is unusual.