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CASE REPORT
Year : 2014  |  Volume : 3  |  Issue : 3  |  Page : 192-194

Gastropleural fistula secondary to strangulated diaphragmatic hernia


Department of Surgery, GSL Medical College, Andhra Pradesh, India

Date of Web Publication17-Sep-2014

Correspondence Address:
Samir Ranjan Nayak
Department of Surgery, GSL Medical College, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.140945

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  Abstract 

Gastro pleural fistula resulting from strangulation and perforation of the fundus in a diaphragmatic hernia in an adult is a rare entity. A 56-year-old male presented with severe dyspnea. Emergency chest X-ray showed left hydropneumothorax with mediastinal shift for which chest tube was placed. Patient improved symptomatically, but liquid food particles started coming through the intercostal chest tube. Gastroscope, contrast fluoroscope and computed tomography chest carried out to detect exact anatomical and pathological diagnosis. Investigations revealed intrathoracic location of the stomach and spleen. Laparoscopy and then midline laparotomy carried out. Fundus of the stomach and spleen were in left pleural cavity through the hernia Bochdalek. There was perforation of prolapsed stomach leading to pyopneumothorax; hence pus drained out through the chest tube and then food particles appeared in the water seal bag. The stomach and the diaphragm were successfully repaired after doing the splenectomy.

Keywords: Diaphragmatic hernia, gastropleural fistula, pyothorax


How to cite this article:
Nayak SR, Soren DK, Rao GB, Kiran G. Gastropleural fistula secondary to strangulated diaphragmatic hernia. J NTR Univ Health Sci 2014;3:192-4

How to cite this URL:
Nayak SR, Soren DK, Rao GB, Kiran G. Gastropleural fistula secondary to strangulated diaphragmatic hernia. J NTR Univ Health Sci [serial online] 2014 [cited 2020 Apr 4];3:192-4. Available from: http://www.jdrntruhs.org/text.asp?2014/3/3/192/140945


  Introduction Top


Bochdalek hernia (BH) is a congenital defect of the posterolateral position of diaphragm resulting from improper fusion of pleuroperitoneal folds.

This hernia usually presents in the newborn and early infant period with pulmonary symptoms. Symptomatic BH in an adult is rare. The symptoms of adult BH varied from dyspepsia, gastroesophageal reflux disease to acute abdomen in the form of intestinal obstruction or perforation.

We describe a case of diaphragmatic hernia in a 56-year-old male presenting as gross left pyopneumothorax secondary to strangulation, perforation of the fundus of the stomach.


  Case report Top


A 56-year-old male patient presented with acute onset of the left side chest pain and shortness of breath. On examination, the patient was febrile, cyanosed with cold clammy skin. His vitals were pulse rate of 96/min feeble, systolic blood pressure of 70 mm Hg and respiratory rate of 42/min. There was decreased chest movement on the left side with tracheal deviation to the right. Decreased breath sounds heard over left hemithorax. Succession splash noted on the left side chest. Bedside chest X-rays showed hydropneumothorax on the left side with mediastinal shift [Figure 1] Intercostal tube drain was placed over left fifth intercostal space. About 2000 ml of pus was drained out. The patient was relieved of dyspnea, but hypotension and tachycardia persisted. Oxygen supplementation, injectable antibiotics and fluid resuscitation continued. Next day the resident observed liquid food particles in the intercostal tube drain. Upper gastrointestinal (GI) endoscopy, contrast fluoroscopy was carried out to exclude esophagus and iatrogenic gut injury [Figure 2]. Contrast-enhanced computed tomography (CECT) chest-abdomen revealed stomach and spleen was in the left pleural cavity [Figure 3]. Laparoscopy followed by midline laparotomy was done. The laparotomy finding was intrathoracic location of the fundus of the stomach and spleen through the hernia of Bochdalek on the left side. The prolapsed fundus of the stomach was strangulated and perforated leading to gross left pyopneumothorax. The gangrenous part of the stomach was resected and primary closure performed. Splenectomy was carried out. The defect over the diaphragm was repaired with prolene suture [Figure 4]. Mesh repair was avoided in view of pyothorax. Feeding jejunostomy was done. Post-operative recovery was satisfactory. The Patient was discharged on 10 th post-operative day after the removal of chest tube.
Figure 1: X-ray chest- left hydropneumothorax with mediastinal shift

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Figure 2: X-ray chest - intercostal tube drainage in situ

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Figure 3: Contrast-enhanced computed tomography chestintrathoracic location of spleen and stomach

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Figure 4: Strangulated part of stomach

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  Discussion Top


Bochdalek described a defect in the diaphragm due to failure of fusion of pleuroperitoneal membranes in the year 1848. The location of defect as described by Bochdalek is at posterolateral position of diaphragm and left sided defect is more common than right. In most instances, the hernia sac is not present hence called as pleuroperitoneal hernia. [1]

The hernia usually presents in paediatric population with respiratory distress. BH in an adult is not common. The incidence of BH containing GI tract is higher than previously reported, but the patients were asymptomatic. [2]

Symptomatic BH in an adult is rare and the symptoms complexes are most often related to aero digestive tract. Dyspnea, chest pain are the predominant respiratory symptoms. The GI symptoms may vary from vague upper abdominal discomfort to an acute emergency in the form of incarcerated bowel related to obstruction or perforation. [3],[4],[5],[6]

Left sided BH may contain stomach, colon, spleen, small bowel, omentum pancreas and adrenal glands. [5],[6]

Fever, tachycardia, cough, dyspnea and chest pain with dullness on percussion is the typical presentation of pyopneumothorax. Emergency treatment being the drainage of fluid through an intercostal chest tube. [7]

Emergency intercostal tube drainage (ICTD) improved the respiratory symptoms, but hypotension and tachycardia were still persisting in our case. Food particles coming through the chest tube raised a suspicion of esophageal rupture from Boerhaave's syndrome or iatrogenic injury during ICTD insertion.

Gastroscope excluded esophageal rupture. Portion of the stomach and spleen lying above the upper surface of left hemi diaphragm in CECT chest and abdomen made a clear picture of diaphragmatic hernia with intrathoracic incarceration of stomach leading to left pyopneumothorax. The defect in diaphragm was congenital. Kishiki et al. in their study have reported similar case of pyothorax due to perforation of prolapsed stomach.[8]

The treatment in symptomatic BH can be performed through abdominal or thoracic approach. In right sided BH transthoracic approach is the best. Controversy is continuing for the approach of the left sided symptomatic BH. However in the presence of bowel obstruction or perforation transabdominal approach is the preferred. In asymptomatic cases, transthoracic may be considered as the chronic adhesions of abdominal viscera and thoracic structure can easily be handled. [4],[5]

Reduction of the contents, repair of the hernia defect with delayed or non-absorbable sutures or Gore-tex mesh is the treatment for BH. In our case midline laparotomy was performed. The contents were reduced and splenectomy was performed. Primary closure of the stomach and then hernia defect was closed with prolene suture.


  Conclusion Top


Placement of ICTD in pyopneumothorax with mediastinal shift is the emergency treatment. Collections of food particles in under water seal bag arouse suspicion of iatrogenic injury. Diaphragmatic hernias is to be kept in mind in entero-pleural fistula in the absence of abdominal signs with persistent hypotension and tachycardia.

 
  References Top

1.Alam A, Chander BN. Adult Bochdalek hernia. Med J Armed Forces India 2005;61:284-6.  Back to cited text no. 1
    
2.Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek's hernia in a large adult population. AJR Am J Roentgenol 2001;177:363-6.  Back to cited text no. 2
    
3.Hamid KS, Rai SS, Rodriguez JA. Symptomatic Bochdalek hernia in an adult. JSLS 2010;14:279-81.  Back to cited text no. 3
    
4.Hung YH, Chien YH, Yan SL, Chen MF. Adult Bochdalek hernia with bowel incarceration. J Chin Med Assoc 2008;71:528-31.  Back to cited text no. 4
    
5.Perch P, Houck WV, DeAnda A Jr. Symptomatic Bochdalek hernia in an octogenarian. Ann Thorac Surg 2002;73:1288-9.  Back to cited text no. 5
    
6.Balaji M, Subramanian C, Ramesh. A case of congenital diaphragmatic adult hernia presenting as acute intestinal obstruction. Indian J Surg 2009;71:169-70.  Back to cited text no. 6
    
7.Sahn SA. Diagnosis and management of parapneumonic effusions and empyema. Clin Infect Dis 2007;45:1480-6.  Back to cited text no. 7
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8.Kishiki T, Shida H, Negishimanato, Higashihisato, Seiichi Y, Masuda K. A case of diaphragmatic hernia with pyopneumothorax due to perforation of the prolapsed stomach. J Jpn Surg Assoc 2006;67:1533-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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