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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 9  |  Issue : 1  |  Page : 36-39

Diaphragmatic eventration mimicking congenital diaphragmatic hernia: The value of chest radiograph and barium meal in diagnosis


Department of Radiology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication10-Oct-2012

Correspondence Address:
Mohammed Kabir Saleh
Department of Radiology/Radiography, Bayero University/Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-8540.102114

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  Abstract 

A 6-month-old boy was referred to the radiology department of the Aminu Kano Teaching Hospital for chest X-ray, from the Emergency Pediatric unit of the Hospital, on account of severe bronchopneumonia in association with diaphragmatic hernia to rule out pulmonary tuberculosis, but for which, chest X-ray and a complimentary urgent Barium meal studies showed a complete left-sided eventration of the hemidiaphragm. He had successful plication of the left hemidiaphragm and the bowel loops, and spleen were carefully freed and fixed back into the abdomen. The paper highlighted on the key role played by the chest X-ray and an immediate complimentary upper gastrointestinal barium studies in making the diagnosis of this life-threatening condition in a resource-poor environment. The relevant literature was also reviewed.

Keywords: Barium Meal, chest X-ray, congenital diaphragmatic eventration/hernia


How to cite this article:
Saleh MK, Suwaid MA, Idris SK, Tabari AM, Isyaku K. Diaphragmatic eventration mimicking congenital diaphragmatic hernia: The value of chest radiograph and barium meal in diagnosis. Niger J Basic Clin Sci 2012;9:36-9

How to cite this URL:
Saleh MK, Suwaid MA, Idris SK, Tabari AM, Isyaku K. Diaphragmatic eventration mimicking congenital diaphragmatic hernia: The value of chest radiograph and barium meal in diagnosis. Niger J Basic Clin Sci [serial online] 2012 [cited 2019 May 23];9:36-9. Available from: http://www.njbcs.net/text.asp?2012/9/1/36/102114


  Introduction Top


Congenital eventration of the diaphragm is due to maldevelopment of the muscular portion of the hemidiaphragm where it is thin and hypoplastic and because of this thinned weakened, musculature is inadequate to restrain abdominal viscera, the diaphragm rises to a more cephalad position than normal, leading to upward displacement of the abdominal viscera. [1],[2],[3] The unbroken continuity differentiates it from diaphragmatic hernia. The continuity and attachments to the costal margin of the diaphragm are also maintained. [4] It is a rare anomaly, occurring in 1 out of 10,000 live births with a male sex and left hemidiaphragmatic preponderance. [5] It represents 5% of all diaphragmatic anomalies and has an anteromedial location on the right and total involvement on the left with a ratio of 5:1. [1],[2] It is frequently not possible to tell if these defects are due to failure of fusion (hernia) or due to focal muscular deficiency (eventration). [6]

Diaphragmatic abnormalities that affect children in increasing order of structural anatomical abnormality are paresis, paralysis, eventration, and hernia. [7]

Chest radiographs, computed tomography, gastrointestinal contrast media examinations, prenatal ultrasound scanning, and MRI have gone a long way in differentiating these various types of congenital diaphragmatic anomalies, sometimes even in the pre- and peri-natal periods. [8],[9],[10],[11]


  Case Report Top


A 6-month-old male baby who presented to the emergency pediatric unit of Aminu Kano Teaching Hospital with 4 months history of cough, respiratory distress, and fever. There was associated vomiting, convulsion, refusal of feeds, and associated loss of weight with failure to thrive. The condition became worse in the last 3 months.

He was the 7 th child in a monogamous family being a product of a full term unsupervised and uneventful pregnancy delivered via spontaneous vertex delivery at home. He had not received any of the routine immunizations. Clinical examination revealed an acutely ill-looking child in severe respiratory distress. The patient was febrile, not pale, anicteric, acyanosed but wasted. Chest examination revealed an increased respiratory rate of 45/minute, asymmetric chest wall (with fullness on the left side), tracheal shift to the right side, dull percussion note with decreased air entry on the left side, and absent breath sounds. The right lung field was clear. The apex beat was displaced to the right side. The heart sounds were I and II only with no murmur. Abdominal examination revealed a scaphoid abdomen that moves normally with respiration. No organomegaly was detected. The central nervous and musculoskeletal systems were essentially normal. An initial clinical impression of acute severe bronchopneumonia with an underlying pleural fluid collection and possible lung collapse to rule out pulmonary tuberculosis was made. Laboratory results of full blood count (FBC), serum urea, electrolytes, creatinine, and urinalysis were all within normal limits.

A chest and abdominal X-ray revealed an area of patchy inhomogeneous opacities with tubular lucencies in the left lung field. These lucencies were also noted to be continuous with the abdominal bowel lucencies. There was also loss of definition of the left hemidiaphragm with blunted costophrenic angle. The left lower lung zone was also devoid of lung markings. There was associated shift of the heart, trachea, and the mediastinum to the right side. The bony thorax was within normal limits. The patient was, however, wasted [Figure 1].
Figure 1: A frontal plain chest radiograph, showing the herniated bowel loops (bent arrow) and stomach (curved right arrow) and the displaced trachea and mediastinum (straight arrow) with associated ill definition of the left hemidiaphram and the costophrenic angle

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Ultrasound scan of the chest, being non-remarkable and inadequate due to excessive gastric and bowel gas reflections in the chest, was, therefore, not included. A suspicion of a left congenital diaphragmatic hernia was made. Barium meal examination showed the stomach and the bowel loops in the left hemithorax coated with barium [Figure 2]a and b. The thin diaphragmatic outline was also visible. The diagnosis of a complete left diaphragmatic eventration was made.
Figure 2: (a) A left lateral view of a series of barium meal films showing the barium coated stomach and bowel loops (star) and the thin diaphragmatic outline (straight upward arrow) (b) An Antero-posterior view of the thorax and abdomen showing the barium-coated herniated stomach and bowel loops with associated ill definition of the left costophrenic angle, shift of the heart and trachea to the right hemithorax

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At surgery, a hypoplastic thin left hemidiaphragm was found with total eventration. No hernia was seen. The stomach, bowel loops, and spleen were displaced from their normal positions. The diaphragm was plicated with a non-absorbable suture while the gut was carefully dissected, freed, and placed back into the abdominal cavity. The spleen was also freed and fixed in its normal position. Immediately, patient's post-operative conditions were satisfactory. Patient was discharged home after 2 weeks post-operative day.


  Discussion Top


Diaphragmatic eventration is the upward displacement of the abdominal viscera secondary to a thin or paralytic diaphragm. Its clinical presentations and radiographic pictures are similar to those of diaphragmatic hernia. [7] Differentiation between congenital diaphragmatic hernia and congenital diaphragmatic eventration is very difficult but important because eventration has a severe perinatal outcome in form of severe respiratory distress, cyanosis, and respiratory failure compared to diaphragmatic hernia. [11],[12]

Eventration could be total or focal. It could be bilateral or unilateral but usually unilateral and left-sided as seen in our patient. In adults, it is usually asymptomatic and may be an incidental radiographic finding. [1] Infrequently non-specific dyspepsia, epigastric discomfort, or burning sensation may be the only symptom. In neonates, cardiopulmonary distress could be the presenting feature as is observed in this patient. [13]

Total eventration occurs almost exclusively on the left and is usually seen in a male [1],[5] as seen in our patient. The peripheral musculature and phrenic nerve are usually intact. Because the thinned, weakened musculature is inadequate to restrain the abdominal viscera, the diaphragm rises and is upwardly displaced together with the abdominal organs. Herniated organs depending on the site include small bowel loops, stomach, spleen, pancreas, kidney, liver, and gall bladder. Posterior eventration of the diaphragm is usually indistinguishable from a Bochdalek hernia. [5] Eventration appears radiologically as a localized bulge or generalized elevation of the diaphragm. [1],[2] This is a case of total eventration as the entire left hemidiaphragm with an unbroken continuity was elevated into the ipsilateral hemithorax as is demonstrated in [Figure 2]a and b.

The condition, if severe, can simulate a congenital diaphragmatic hernia in a newborn and may be complicated with pulmonary hypoplasia and/or pulmonary hypertension. [14] At fluoroscopy, movement of the diaphragm may be normal or diminished, and absent respiratory excursion on the affected side may be noted. [2],[7] Paradoxical diaphragmatic motion is occasionally demonstrated though it is much more commonly seen in patients with paralysis of the diaphragm. [1] The passing of an N-G tube under fluoroscopic control will show it entering the intrathoracic stomach. These were not demonstrated in this patient as fluoroscopy was not employed in the Barium examination. The cardiomediastinal structures may be displaced toward the contralateral side with resultant severe compromise to the cardiopulmonary function, [12] as seen in this patient.

Barium meal examination would show a barium-coated intrathoracic stomach and bowel loops, while diaphragmatic outline may be ill-defined or indiscernible. The affected lung is usually collapsed as seen in this patient.

Prenatal diagnosis of the condition is possible and is usually best made with ultrasound scan at 18-20 weeks gestation. [2],[8] It may be shown as a solid, multicystic, or complex chest mass with lateral displacement of the heart and paradoxical motion of the diaphragm with fetal breathing. The fetal abdomen would be scaphoid with reduced abdominal circumference, while the fetal stomach would be at the level of the heart. [2],[6],[8] Herniated liver and the spleen would also be seen in the chest. Ultrasound scan findings were grossly inadequate in this patient due to the excessive reflective gas within the herniated stomach and the bowel loops, hence not included.

In eventration, the collapsed lung is prone to recurrent infection and even bronchiectasis, so early repair should be instituted. [14],[15] The repair of diaphragmatic eventration is done by plication with non-absorbable suture. [16],[17] Although surgical thoracotomy has been the main surgical technique, a repair under video-assisted thoracoscopy has been recently introduced as this offers advantage of minimally invasive surgery. [18] This patient had successful placation of the affected left hemidiaphragm using an absorbable suture.

Chest radiography and barium studies of the upper gastrointestinal tract are very important imaging modalities in a resource-poor environment such as ours for the evaluation of patients with suspected diaphragmatic anomalies and should, therefore, be employed, especially in highly suspicious cases as this saves life of the patient and also avert long term life-threatening complications.

 
  References Top

1.Ronald LE. Gastrointestinal radiology. 2 nd ed. USA: JB Lippincott Company; 1990. p. 152-3.  Back to cited text no. 1
    
2.Wolfgang Dahnert MD. Radiology review manual. 6 th ed. Baltimore, Maryland USA: Lippincott Williams and Wilkins Company; 2007. p. 491-2.  Back to cited text no. 2
    
3.Kulkarni ML, Sneharoopa B, Vani HN, Nawaz S, Kannan B, Kulkarni PM. Eventration of the diaphragm and associations. Indian J Paed 2007;74:202-5.  Back to cited text no. 3
    
4.Mantoo, SK, Mak K. Congenital diaphragmatic eventration in an adult: A diagnostic dilemma. Singapore Med J 2007:48:136-7.  Back to cited text no. 4
    
5.Soni A, Singh P, Singh RJ, Sood V. Eventration of diaphragm - Embryologic basis. J Anat Society India 2005;54:1-9.  Back to cited text no. 5
    
6.Merten DF. Anteromedial diaphragmatic defects in infancy: Current approaches to diagnostic imaging. Radiology 1982;142:361.  Back to cited text no. 6
    
7.Donald RK, editor. Diagnostic radiology of infants and children: In Practical paediatric Imaging. 2 nd ed.. New York: Little Brown and Company; 1991. p. 552-3 and 742.  Back to cited text no. 7
    
8.Yang CK, Shih JC, Hsu WM, Peng SS, Shyu MK, Lee CN, et al. Isolated right diaphragmatic eventration mimicking congenital heart disease in utero. Prenantal Diagnosis 2005;25:872-5.  Back to cited text no. 8
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9.Tsukahara Y, Ohno Y, Itakura A, Mizutani S. Prenatal diagnosis of congenital diaphragmatic eventration by magnetic resonance imaging. Am J Perinatol 2001;18:241-4.  Back to cited text no. 9
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10.Eren S, Ceviz N, Alper F. Congenital diaphragmatic eventration as a cause of anterior mediastinal mass in the children: Imaging modalities and literature review. Eur J Radiol 2004;51:85-90.  Back to cited text no. 10
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11.Salami MA, Adebo OA. Congenital diaphragmatic eventration in a Nigerian child. Nig J Med 2005;14:317-8.  Back to cited text no. 11
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12.Jeong IY. Left diaphragmatic eventration diagnosed as congenital diaphragmatic hernia by prenatal sonography. J Clin Ultrasound 2003;31:214-7.  Back to cited text no. 12
    
13.Tsugawa C, Kimura K, Nishijima E, Muraji T, Yamaguchi M. Diaphragmatic eventration in infants and children: Is conservative treatment justified? J Paediatr Surg 1997;32:1643-4.  Back to cited text no. 13
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14.Groth SS, Andrade RS. Diaphragm plication for eventration or paralysis: A review of the literature. Ann Thorac Surg 2010;89:S2146-50.  Back to cited text no. 14
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15.Adeniyi TO, Bello TO. Typical and atypical presentations of congenital diaphragmatic hernia - A report of 2 cases. Niger Postgrad Med J 2008;15:264-6.  Back to cited text no. 15
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16.Nixon H, O'Donnell B. Essentials of paediatric surgery. 4 th ed. UK: butterworth heinemann Ltd; 1992. p. 297.  Back to cited text no. 16
    
17.Imamoghu M. Congenital diaphragmatic eventration: Treatment and post-operative evaluation. J Cardiovasc Surg 1996;37:173-6.  Back to cited text no. 17
    
18.Mouroux J, Padovani B, Poirier NC, Benchimol D, Bourgeon A, Deslauriers J, et al. Technique for the repair of diaphragmatic eventration. Ann Thorac Surg 1996;62:905-7.  Back to cited text no. 18
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