An unusual cause of dyspnea and tachycardia

Key Clinical Message

Diaphragmatic hernias are typically congenital or caused by trauma. Delayed presentation is not uncommon. Repair can be undertaken through an open or minimally invasive abdominal or thoracic approach. Small defects can be repaired with sutures, while larger defects require a mesh repair. This patient's comorbidities precluded him from surgery.

Question

A 77‐year‐old man presented with new‐onset dyspnea. Examination revealed a respiratory rate of 28, a heart rate of 160, and oxygen saturations of 87% on room air. Gurgling sounds were heard on auscultation of the left chest. The appearance of bowel on the chest X‐ray prompted a computed tomography scan. Can you identify the irregularity in the images?

Answer

This man's transverse colon, stomach, and head of pancreas are lying in his chest below the arch of his aorta (Figs. 1, 2, 3). This hernia is caused by a defect in the posterior aspect of his diaphragm. The hernia contents are intermittently compressing his heart and great vessels causing his symptoms. Interestingly, the patient did not recall a history of trauma.

Figure 1.

Chest X‐ray: bowel is visualized in the thorax

Figure 2.

Coronal CT scan: green arrow – arch of aorta, red arrow – transverse colon

Figure 3.

Sagittal CT scan: there is clear evidence of thoracic spine kyphosis. Green arrow – arch of aorta, red arrow – transverse colon, blue arrow – diaphragmatic defect.

Conflict of Interest

None declared.