Indolent presentation of a right-sided spontaneous diaphragmatic hernia: A case report and review of the literature

Introduction and Importance

Diaphragmatic hernias are the herniation of abdominal contents through the diaphragm into the thorax and are categorized as congenital or acquired. Most commonly, acquired diaphragmatic hernia is preceded by blunt or penetrating trauma to the abdomen with the former occurring more frequently. In less than 1% of cases, acquired diaphragmatic hernias can occur spontaneously, which can be recognized incidentally on imaging or by patients presenting with non-specific symptoms. Without prompt diagnosis, patients are at risk for incarceration and strangulation of the herniated contents, resulting in bowel necrosis.

Case presentation

Here, we present the case of a 36-year-old male who presented with worsening 3-month history of dyspnea and palpitations. Initial clinical exam was notable for tachypnea and accessory muscle recruitment. Auscultation revealed bowel sounds in the right lung fields. Semi-upright chest radiograph uncovered a large right-sided pneumothorax containing portions of the stomach, liver, and numerous loops of bowel, with significant cardiomediastinal left shift. Surgical intervention for diaphragmatic hernia repair was promptly planned.

Clinical discussion

Spontaneous diaphragmatic hernia occurring secondary to a defect on the right side of the diaphragm without any history of trauma or surgery is an extraordinarily infrequent pathology. This subacute clinical presentation despite extensive anatomic involvement highlights the importance of thorough physical examination, with auscultation of bowel sounds in the thorax serving as a near pathognomonic finding for a spontaneous diaphragmatic hernia, including patients without a known history of acute trauma or previous surgery.

Conclusion

Surgical management of such rare hernias via abdominal, thoracic, or a combined approach coupled with pulmonary monitoring proves to be an effective treatment, and awareness of this case will aid in its identification and the ability to provide prompt intervention.