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Small bowel strangulation due to peritoneopericardial diaphragmatic hernia
© Lee and Kim; licensee BioMed Central Ltd. 2014
Received: 31 December 2013
Accepted: 20 March 2014
Published: 2 April 2014
A 75-year-old Korean man was referred to our hospital with cramping abdominal pain. His chest X-ray showed an abnormal air shadow above the diaphragm, and computed tomography showed an abdominal viscera in the pericardium. We performed surgery and confirmed peritoneopericardial diaphragmatic hernia with small bowel strangulation. Postoperative course was uneventful. Peritoneopericardial diaphragmatic hernia is very rare in humans, so we report the case with a literature review.
A peritoneopericardial diaphragmatic hernia is one that permits direct communication between the peritoneal and pericardial cavities through a defect in the diaphragm. It is very rare in humans. The cause of peritoneopericardial diaphragmatic hernia varies, as some authors have reported [1–5]. We herein report a case of peritoneopericardial diaphragmatic hernia with small bowel strangulation in a 75-year-old Korean man.
A peritoneopericardial diaphragmatic hernia is one that permits direct communication between the peritoneal and pericardial cavities through a defect in the diaphragm. It is very rare in humans. Peritoneopericardial hernia may be congenital, arising from the failure of development of the transverse septum , or may follow rupture of the diaphragm after trauma [2, 3]. A surgical cause has also been reported [4, 5]. Since our patient had a defect of the central tendon of the diaphragm with peritoneopericardial communication and no history of trauma, we concluded that the defect was congenital. The signs and symptoms of peritoneopericardial diaphragmatic hernia are dyspnea, cyanosis, palpitation, and chest pain; if viscera become incarcerated, signs and symptoms of intestinal obstruction are added . Cardiac tamponade and pericardial effusions are unusual, but have been reported [7, 8]. Our patient had dyspnea, chest discomfort and symptoms of viscera incarceration. When diaphragmatic hernia is suspected, an x-ray of the chest will demonstrate viscera above the diaphragm. The chest x-ray is abnormal in the majority of cases, usually showing air within the pericardium . In 1947, Wilson et al. described the radiographic appearance of the peritoneopericardial diaphragmatic hernia . Our patient had an abnormal chest radiographic appearance that showed abnormal air shadows above the diaphragm and confirmed the computed tomography. The only definitive treatment for peritoneopericardial hernia is surgery. In 1907, Wilson et al. reported the first case successfully corrected with surgery . Some authors suggest that a thoracotomy incision is the only logical surgical approach . But the logical operative approach may vary, depending on the acuity and associated conditions . In the case of acute herniation, in which abdominal viscera injuries present, repair from an abdominal approach is indicated. However, in chronic situations, adhesion to the pericardium and heart are likely to have developed, making exposure through the chest more desirable . Repair procedures for the defect depend on the size of the defect. Primary repair with nonabsorbable suture is satisfactory when the diaphragmatic margins are easily approximated without tension, but a large defect requires patch repair . In our case, the patient had cramping abdominal pain, so we suspected strangulation of the abdominal viscera. We therefore performed median laparotomy. The margin of the defect was thick and not easily approximated, so we performed a patch repair of the defect.
A case of small bowel strangulation due to peritoneopericardial hernia and successfully corrected surgically is reported. Abnormal air shadow above the diaphragm on chest x-ray led us to suspect a type of diaphragmatic hernia. Computed tomography is one of the best diagnostic methods. The clinician should be aware of peritoneopericardial diaphragmatic hernia, however rare this condition. If peritoneopericardial diaphragmatic hernia is confirmed, surgical repair should be performed.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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