When the scope would not pass: Diaphragmatic hernias

Diaphragmatic hernias are among the conditions that need strong clinical suspicion for diagnosis. This is due to their rare incidence combined with varied and nonspecific presentation. These patients are often diagnosed with lux disease or non-ulcer dyspepsia. Moreover, the importance of prompt diagnosis and surgical repair is strengthened by their potential of causing acute gastric volvulus [1]. We encountered two such cases which were diagnosed with diaphragmatic hernias in the context of difficult upper GI endoscopy while being evaluated for non-specific abdominal pain.

Case 1

Our patient, a 25-year-old male presented with 15 days history of dull left-sided upper abdominal pain associated with induced vomiting upon which pain was relieved. Vomitus contained the previous day’s ingested food material. This patient gave history of a road traffic accident four months prior to this presentation. Physical examination was unremarkable.

All the blood parameters including complete blood count (CBC), liver function tests (LFT), renal function test (RFT), and blood sugar profile were within normal range. During evaluation by upper GI endoscopy, it proved very difficult to pass the scope beyond the stomach due to looping of the endoscope in the proximal stomach. This was the key behind the suspicion of a possible anatomical aberration.

Endoscopic view showed that the stomach appeared occluded and a constriction like appearance was seen just adjacent to the fundus. The scope was negotiated with difficulty beyond the apparent occlusion leading to a normal appearing distal gastric body, antrum, and pylorus.

For further evaluation, contrast-enhanced computed tomography (CT) scan and an upper GI series were performed which demonstrated that almost the entire stomach occupied the left side of the mediastinal cavity above the left hemi-diaphragm (Figure 1 and Figure 2).

The stomach passed through a gap in the medial part of the left hemi-diaphragm. There was splitting of the muscle fibers of the left crus of the diaphragm near its insertion on the vertebra.

The gastroesophageal junction (GEJ) was in place but the gastro-duodenal junction was displaced supero-laterally on the left. Computed tomography films provided additional information suggestive of rotation of the stomach along its long axis, consistent with a partial gastric volvulus (Figure 1 and Figure 3). Chest X-ray (CXR) posteroanterior (P/A) view in erect posture revealed the position of the fundic gas shadow to be above the left hemi-diaphragm (Figure 4).

A diagnosis of diaphragmatic hernia with partial organo-axial gastric volvulus was made based on the clinical presentation, endoscopic appearance, and imaging evidence.

Treatment

The patient was erred to the surgical unit for reduction of the herniated stomach and repair of the diaphragmatic defect.

The abdomen was approached via a left subcostal incision. Per operative findings described a large (15 × 10 cm) defect at the left dome of the diaphragm near the esophageal opening. The stomach and omentum had herniated through the gap. The left lobe of the liver was mobilized and the hernial contents were reduced. The defect was repaired and the abdomen was closed in layers keeping a left subdiaphragmatic drain in situ.

Outcome and follow-up

The patient was discharged on third post-operative day (POD) with an uneventful post-operative period. At his two month follow-up the patient had recovered fully without any complications. Post-operative X-rays showed a repositioned stomach within the abdominal cavity (Figure 5).

Case 2

Our second patient is a 32-year-old male who presented with dyspepsia and upper abdominal pain for two months. He did not have history of vomiting or weight loss. His appetite and bowel movement were normal. There was no significant background history and did not recall any trauma prior to admission. Physical examination was unremarkable. He was advised an upper GI endoscopy along with other blood parameters for evaluation of his upper GI complaints.

All the blood parameters including complete blood count (CBC), liver function tests (LFT), renal function test (RFT), blood sugar profile, and pancreatic enzymes were within normal limits.

Similar to the first case mentioned above, difficulty was faced while attempting upper GI endoscopy and the scope could not be negotiated. Further evaluation with CT scan revealed displacement of the stomach into the left hemi-thorax (Figure 6 and Figure 7).

Management and outcome

This patient also underwent open surgical repair. Operative and post-operative period was uneventful. The chest drain was removed on the 2nd POD and he was discharged on the 4th POD after post-operative recovery. Routine follow-up revealed that the incision site had healed normally without any complications. Comparison of the pre- and post-operative X-rays showed reduction and reposition of the hernia contents from the chest cavity into the abdominal cavity (Figure 8). The patient remains well and symptom free till date.

A diaphragmatic hernia is described as displacement of the abdominal contents into the chest cavity through any weak point in the diaphragm. Diaphragmatic hernias include hiatal hernias, para-esophageal hernias, congenital hernias, and traumatic hernias.

There are four types of hiatal hernias. Type I is also known as sliding hernia. It is the most common type (90%) and involves displacement of the GEJ above the diaphragm. Type II represents displacement of the stomach above the diaphragm. In type III hiatal hernia, both the GEJ and stomach are displaced and type IV hiatal hernia is accompanied by transposition of any organ other than the stomach [2],[3]. Type II, III, and IV are known as para-esophageal hernias and type III may rarely be associated with gastric volvulus [4].

Most patients with hiatal hernias remain asymptomatic and are diagnosed incidentally. Some may present with lux and abdominal discomfort wherein others, a large hiatus hernia is often responsible for chronic blood loss and anemia [5]. Hiatal hernias can result from any cause that raises intra-abdominal pressure such as obesity, pregnancy, abdominal trauma, etc. There is no association with the size of the hernia and clinical symptoms [6].

Acquired diaphragmatic hernias comprise less than 50% of diaphragmatic injuries and are mostly traumatic [7]. Patients often give history of a blunt trauma or road traffic accident [8] and remain undiagnosed in up to 33% cases during the immediate post-traumatic period [9]. The reason behind this delay in diagnosis is often poor clinical suspicion along with the varied clinical presentation. This scenario is consistent with our first case study who reported a road traffic accident four months prior to his diagnosis. A simple chest X-ray (CXR) can give a clue of transposition of abdominal contents in the mediastinum. Computed tomography scan further provides diagnosis of diaphragmatic injury and herniation with a sensitivity and specificity of 71% and 100% respectively [9]. In both of our cases the strongest degree of clinical suspicion arose when upper GI endoscopic procedure proved to be troublesome without any apparent cause of difficulty. When the reason behind this was further evaluated with barium studies and CT imaging, only then was the defect identified. Our first patient had an associated partial organo-axial gastric volvulus as well.

Surgical reduction of the hernia sac and its contents along with repair of the diaphragmatic defect is the mainstay of treatment. Surgery can be done laparoscopically or via thoraco-abdominal incision. Prosthetic mesh reinforcement can be used to ensure adequate closure of the defect [4].

In patients with a history of abdominal trauma and upper GI symptoms, a diaphragmatic hernia is always a possibility. As specialists, whenever we encounter difficulties in negotiating a scope the probability of any anatomical distortion should be kept in mind regardless of suggestive clinical background.