Bochdalek hernia

Bochdalek hernia

Characteristics

  1. Congenital anomaly with defective fusion of the posterolateral pleuroperitoneal layers.
  2. 85–90% on the left, 10–15% on the right. Usually unilateral lying posteriorly within the chest.
  3. Hernia may contain fat or intra-abdominal organs.
  4. In neonates the hernia may be large and present in utero. This is associated with high mortality secondary to pulmonary hypoplasia (60%).
  5. Small hernias are often asymptomatic containing a small amount of fat only. They have a reported incidence up to 6% in adults.

Clinical features

  1. Large hernias are diagnosed antenatally with US.
  2. Neonates may present with respiratory distress early in life. Early corrective surgery is recommended.
  3. Smaller hernias are usually asymptomatic with incidental diagnosis made on a routine CXR.
  4. Occasionally solid organs can be trapped within the chest compromising the vascular supply. Patients report localised pains and associated organ-related symptoms, e.g. change in bowel habit.

Radiological features

  1. CXR – a well-defined, dome-shaped soft tissue opacity is seen midway betweenthespine andthe lateralchestwall.Thismay ‘comeandgo’.There may be loops of bowel or gas-filled stomach within the area. The ipsilateral lung may be smaller with crowding of the bronchovascular markings and occasionally mediastinal shift. AnNGtubemay lie curled in the chest.
  2. CT – small hernia are difficult to demonstrate even on CT. Careful inspection for a fatty or soft tissue mass breaching the normal smooth contour of the posterior diaphragm.

Differential diagnosis

  1. In neonates, both congenital cystic adenomatoid malformation (CCAM) and pulmonary sequestration may have similar features. Cross-sectional imaging with CT _ MRI utilising 2D reformats is often very helpful.
  2. In adults, the plain film findings mimic pulmonary neoplasms, bronchogenic cysts and infections (_ cavitation).

Management

  1. Large hernias in neonates require early surgical repair. They may also require respiratory support.
  2. In adults no active management is required in asymptomatic individuals.

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