An 18-year-old male patient was referred for decompression colonoscopy having been
admitted 2 days previously for bowel obstruction.
Upon admission, the patient had slight abdominal distension. Analgesic and laxative
treatments were initiated but proved ineffective, and conventional radiography showed
increasing distension of the cecum. Colonoscopy was performed up to the left colonic
flexure ([Fig. 1 a]), and radiographic contrast agent did not reach the transversum ([Fig. 1 b]). Abdominal computed tomography confirmed a mechanical ileus with herniation of
the left colon flexure. Laparotomy was performed, and a 3 cm wide hiatus was found
in the dorsolateral part of the diaphragm. The hernia was reposed, the diaphragm sutured,
and part of the great omentum resected because of ischemia. The patient recovered
without complications and was discharged 7 days postoperatively.
Fig. 1 a Mucosa in the left flexure. b Radiographic examination during colonoscopy; left flexure filled with contrast agent,
lateral to the heart. Gastric tube in situ.
The prevalence of congenital diaphragmatic hernias is reported to be 4.8/10000 births
[1]
[2]
[3]. If symptoms of congenital diaphragmatic herniation manifest later, in children
or adults, gastrointestinal problems such as nausea, vomiting, abdominal pain, or
bowel obstruction are most common [3]. In some reports of late-presenting hernias, bowel stricture was misdiagnosed as
pneumothorax, basal pneumonia, or empyema [4]
[5]. Diagnosis is most often established with computed tomography.
The most common congenital hernia (prevalence 6 %), occurs in the posterolateral parts
of the left diaphragm, and is known as Bochdalek’s hernia [5]. Retrosternal hernia occurring on the right side, known as Morgagni’s hernia, or
retrosternal left-sided hernia, known as Larrey’s hernia, is less common ([Fig. 2]). We believe that the most likely cause of our patient’s problem was a rare, late
manifestation of a congenital diaphragmatic hernia of none of the above-described
types. Regardless of classification, symptomatic diaphragmatic hernia is a rare cause
of mechanical bowel obstruction in young adults. If colonoscopy is performed, concurrent
radiographic investigations can be helpful.
Fig. 2 Localization of hiatal hernias (with kind permission of R.W. Günther, MD, Department
of Diagnostic Radiology, University of Aachen, Germany). 1. Hiatal hernia; 2. Morgagni’s
hernia right; 3. Larrey’s hernia left; 4. Traumatic hernia; 5. Bochdaleck’s hernia;
6. Caval hiatus in the diaphragm.
Endoscopy_UCTN_Code_CCL_1AD_2AJ
