Abstract Introduction Diaphragmatic hernias (DH), either congenital or acquired, are rare in adults and often discovered incidentally. Around one-third of adults with DH present with non-specific respiratory or gastrointestinal symptoms. Large hernias can closely mimic pneumothorax due to respiratory distress and mediastinal shift. We present a patient with DH who developed acute respiratory distress initially suspected to be due to a pneumothorax. Case description A 77-year-old female with Crohn’s disease status post colectomy with end ileostomy and multiple abdominal surgeries for small bowel obstruction (SBO), was admitted for elective right hip arthroplasty. Her postoperative course was complicated by SBO and aspiration pneumonia, requiring brief intubation for one day and was extubated to 2 litres per minute oxygen via nasal cannula. Two days after extubation, she developed acute respiratory distress requiring escalation to a nonrebreather mask. Examination revealed heart rate 87 beats/minute, blood pressure 110/70 mmHg, respiratory rate 29 breaths/minute, and decreased breath sounds over the left hemithorax, raising concern for pneumothorax. Chest radiograph showed a large left sided lucency with rightward mediastinal shift. Point-of-care ultrasound (POCUS) demonstrated preserved lung sliding in left anterior chest, inconsistent with pneumothorax. Given her history of chronic diaphragmatic hernia and findings on POCUS, chest computed tomography (CT) was performed, revealing large left diaphragmatic hernia containing intrabdominal organs, causing near-complete left lung atelectasis. Nasogastric decompression led to rapid improvement in respiratory distress. Surgical evaluation favored conservative management due to her extensive surgical history and elevated operative risk. Over the following week, she demonstrated gradual clinical improvement and was discharged to a skilled nursing facility with outpatient abdominal and thoracic surgery follow up. Discussion While diaphragmatic hernias are frequently encountered in pediatric populations, adult presentations are rare and often underrecognized. DH are reported to be the most common condition misdiagnosed as pseudo-tension pneumothorax. Misdiagnosis can lead to inappropriate chest tube placement with potential injury to herniated organs. Distinguishing features include the presence of gastrointestinal symptoms, absence of trauma or positive pressure ventilation, prior imaging demonstrating hernia, and preserved lung sliding on POCUS. CT imaging is often diagnostic when feasible. This case emphasizes the importance of including diaphragmatic hernia in the differential diagnosis of apparent pneumothorax, particularly in patients with prior abdominal surgeries or known diaphragmatic defects. Awareness of this potential mimic is essential to prevent iatrogenic complications and ensure appropriate management. Figure: Chest radiograph showing a large left-sided lucency with rightward mediastinal shift. This abstract is funded by: None
Kaur et al. (Fri,) studied this question.