C43-43 Severe Case of Massive Non-Traumatic Diaphragmatic Hernia Leading to Fatal Bowel Obstruction

Abstract Introduction Diaphragmatic hernia is defined as protrusion of abdominal viscera through the congenital or an acquired opening in the diaphragm into the thorax. Bowel obstruction in majority of cases is caused by adhesions from prior surgeries. Diaphragmatic hernia leading to bowel obstruction is rare. Here we present a case of severe diaphragmatic hernia leading to bowel obstruction. Case summary An 80-year-old male initially presented to hospital for worsening shortness of breath and worsening lower extremities swelling. His initial lab work showed elevated WBC, lactic acidosis, elevated proBNP, in the emergency department he had chest x-ray done which was abnormal and CT scan of the chest done which showed massive hiatal hernia with multiple bowel loops in the chest causing mediastinal shift with bowel obstruction and gangrene. Patient clinical status rapidly deteriorated even after fluid resuscitation, and he required multiple vasopressors. He was started on antibiotics and general surgery was consulted. Due to his advanced age and multiple comorbidities, the family decided to go with palliative and comfort care measures and patient passed away peacefully. Discussion Non-Traumatic Diaphragmatic hernias are usually seen in neonates with congenital defects. Diaphragmatic hernia is classified into 3 categories including congenital, acquired and traumatic. Main causes of nontraumatic diaphragmatic hernia in adults include congenital weakness, iatrogenic factors including complication from prior surgeries, prolonged infections and muscle atrophy. Spontaneous nontraumatic diaphragmatic hernias are very rare. They are more commonly seen on the left side, about 75% of the diaphragmatic hernia are on the left side however, Burgos etal defined more mortality with right side diaphragmatic hernia1. Small Bowel obstruction (SBO) caused by diaphragmatic hernia can be challenging as high suspicion is required and can lead to delay in diagnosis and treatment. About 80% of bowel obstructions are small bowel Obstructions with adhesions as a most common cause. Nontraumatic diaphragmatic hernia leading to small bowel obstruction is very rare and only a few cases are available in literature. Complications of diaphragmatic hernia include respiratory failure, strangulation of intestine, diaphragm rupture, and possible cardiac tamponade2. Treatment options include respiratory and circulatory resuscitation and ultimately surgery with multidisciplinary approach. Gaspar & etal defined mortality rate of 5-50% depending on co-morbidities. Conclusion Bowel obstructions are common emergencies seen on daily basis, a diaphragmatic hernia leading to bowel obstruction is rare. Physicians need to be aware of this complication of nontraumatic diaphragmatic hernia in adults as early diagnosis and management can improve clinical outcomes. This abstract is funded by: None