Non‐Traumatic Diaphragmatic Hepatic Hernia: A Rare Case of Liver Herniation Into the Lung

ABSTRACT

A 65‐year‐old female presented for abnormal CT for lung cancer screening showing bilateral lung nodules. The left nodule was confirmed as a left‐sided hernia through esophagogastroduodenoscopy (EGD), but a CT‐guided biopsy of the right‐sided 2.3 cm nodule showed benign liver parenchyma. She underwent a liver/spleen scan confirming hepatic tissue in the right lower lobe which was contiguous with the liver. While hiatal hernias are common, a non‐traumatic diaphragmatic hepatic hernia into the lung is a rare clinical case that warrants discussion about diagnosis, causes and interventions.

We describe an unusual case of a right‐sided diaphragmatic hepatic hernia in a 65‐year‐old woman, discovered during routine lung cancer screening and initially suspected to represent a pulmonary malignancy. This case highlights the diagnostic challenges associated with diaphragmatic herniation of solid abdominal organs and interventions to reduce complications.

1. Introduction

Hepatic herniation into the thoracic cavity is a rare condition typically linked to trauma, surgery, or congenital defects and may mimic pulmonary malignancies on imaging. In asymptomatic patients, hernias are often discovered incidentally. We describe an unusual case of a right‐sided diaphragmatic hepatic hernia in a 65‐year‐old woman, discovered during routine lung cancer screening and initially suspected to represent a pulmonary malignancy. This case highlights the diagnostic challenges associated with diaphragmatic herniation of solid abdominal organs and interventions to reduce complications.

2. Case Report

A 65‐year‐old female underwent routine annual CT scans for lung cancer screening, which revealed bibasilar pulmonary nodules (Figure 1A,B). She reported no personal or family history of cancer and denied any environmental or occupational exposures. An EGD identified the left lower lobe nodule as a hiatal hernia, which contributed to significant reflux symptoms. A PET/CT scan (Figure 1C) showed indeterminate mild hypermetabolic activity in the right lower lobe nodule. Given her PET/CT scan results and her prior 12‐pack‐a‐year smoking history, there was an elevated risk of malignancy for the right‐sided nodule, warranting a CT‐guided biopsy (Figure 1D). Pathology on the right‐sided nodule indicated benign liver tissue, and a liver/spleen scan (Figure 1E) confirmed a hepatic hernia through the diaphragm and into the right lower lobe. A chest x‐ray (Figure 1F) done 12 years prior showed a similar small obtrusion into the right lower lobe of the lung from the liver, meaning that her hepatic hernia had a high likelihood of being present since birth.

FIGURE 1.

Multimodal imaging demonstrates a stable right lower lobe hepatic hernia with associated left hiatal hernia, confirmed by PET/CT, liver/spleen scan and biopsy. (A) CT chest sagittal view of right lower lobe hepatic hernia. (B) CT chest coronal view of large right hepatic hernia and left hiatal hernia. (C) PET/CT showing mildly hypermetabolic RLL hepatic hernia. (D) CT‐guided biopsy confirming successful biopsy of 2.3 cm RLL nodule. (E) Liver/spleen scan confirming liver tissue in the right lower lobe of the lung contiguous with the liver. (F) Chest x‐ray from 12 years prior visualising the similarly sized right hernia.

While the right‐sided hernia was asymptomatic, her left‐sided hiatal hernia led to worsening reflux symptoms, including cough, epigastric pain and heartburn. A multi‐disciplinary discussion with the patient, cardiothoracic surgery, interventional pulmonology and a hepatopancreaticobiliary specialists determined that bilateral diaphragmatic repair would be perused to minimise potential complications. The left hiatal hernia was repaired laparoscopically with mesh and fundoplication. Simultaneously, she underwent robotic‐assisted laparoscopic diaphragmatic right hernia repair, reducing the hernia into the abdomen before closing the diaphragmatic defect with sutures and reinforcing it with mesh. Bibasilar hernias were successfully reduced without complications and the patient discharged stable.

3. Discussion

Hernias most often occur in the non‐muscular, weakest point of the diaphragm. Congenital hepatic hernias, as seen in this case, are rarer than provoked hernias. Congenital diaphragmatic hernias are caused by the failure of the pleuroperitoneal membrane to close during the foetal period. Right‐sided hernias are less observed due to the protective support of the liver underneath the right diaphragm and are typically caused by congenital defects such as Bochdalek's hernias. While left‐sided hernias account for around 84% of all diaphragmatic hernias, right‐sided hernias are often larger and carry higher associated mortality, making timely repair critical [1].

Hepatic herniation is occasionally associated with spontaneous diaphragmatic rupture. Ten percent of reported herniations affect the liver, making hepatic herniation an uncommon but clinically significant presentation [2]. Surgical intervention is typically recommended to prevent spontaneous diaphragmatic rupture in patients presenting with symptoms such as abdominal or thoracoabdominal pain, nausea, vomiting and dyspnea [3]. However, bilateral diaphragmatic hernias, as seen in our patient, presents a unique surgical challenge due to increased complexity and risk of complications. Despite this, studies have shown that simultaneous bilateral hernia repair carries a postoperative mortality rate comparable to that of unilateral repair [4]. Given the patient's symptomatic left‐sided hiatal hernia requiring surgical correction, concurrent repair of the right hepatic hernia was pursued to mitigate risk of future complications. Surgical repair, particularly in patients with bilateral herniation or symptomatic presentation, will reduce life‐threatening complications associated with spontaneous rupture.

Surgical repair of right‐sided diaphragmatic hernias can be done through video‐assisted thoracoscopic surgery (VATS), thoracotomy, laparoscopy, laparotomy or a combined thoracic and abdominal approach. Right‐sided diaphragmatic hernias can be difficult to reduce via a thoracic approach, with studies showing that up to half of such cases require conversion to laparotomy. Therefore, a laparotomy or laparoscopy should be considered, as demonstrated in our case.

Diaphragmatic hepatic hernias mimic pulmonary nodules and thus are particularly challenging to identify. The similarities between benign hepatic lesions and pulmonary malignancies complicate the differential diagnosis. PET/CT scans, including the one performed on our patient, may demonstrate physiological avidity that closely resembles that of malignant neoplasms. However, such findings should not be definitively interpreted as indicative of malignancy. Infections and hypermetabolic organs, like the liver, can also exhibit similar uptake. The differential for our patient leaned more towards malignancy over infection, which would typically present with fever and congestion. A biopsy of the nodule, via bronchoscopy or CT‐guided approach, is warranted given the potentially fatal implications of malignancy. If benign lung parenchyma is found, a liver/spleen scan, using radioactive technetium‐99 m sulphur‐colloid, can radiographically confirm hepatic herniation [5]. Although exceedingly rare, hepatic hernias should be considered in the differential for nodules contiguous with the diaphragm albeit at a lower priority than more common etiologies such as infection and malignancy.

Diaphragmatic hepatic hernias are rare and often asymptomatic but can mimic pulmonary malignancies on imaging. Biopsy remains essential for accurate diagnosis, and surgical repair should be considered, particularly in bilateral cases, to prevent future complications such as spontaneous rupture.

Author Contributions

Alexander J. Sweidan conceived and designed the study. Ivan H. Huang supervised the project and wrote and revised the initial manuscript. Saarang Kashyap and Kenneth N. Dang collected and analysed the data. All authors reviewed the manuscript and contributed to data interpretation.

Consent

The authors declare that written informed consent was obtained for the publication of this manuscript and accompanying images using the consent form provided by the Journal.

Conflicts of Interest

The authors declare no conflicts of interest.

Huang I. H., Kashyap S., Dang K. N., and Sweidan A. J., “Non‐Traumatic Diaphragmatic Hepatic Hernia: A Rare Case of Liver Herniation Into the Lung,” Respirology Case Reports 13, no. 6 (2025): e70250, 10.1002/rcr2.70250.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.