Cough-induced Transdiaphragmatic and Intercostal Herniation of the Liver

After a single episode of violent cough, a 62-year-old morbidly obese woman developed acute dyspnea and a noticeable bulge with severe pain and ecchymosis over the right flank. Her symptoms progressed over 3 months with increasing soft tissue fullness. She denied fevers or gastrointestinal symptoms. A tender, partially reducible soft tissue mass was noted. Chest computed tomography demonstrated a large right lateral transdiaphragmatic intercostal hernia (TDIH; Figures 1A–D). There was no history of thoracoabdominal surgeries, connective tissue disease, or prior trauma. A thoracotomy was performed, revealing extensive herniation of the diaphragmatic sulcus and the lower chest and lateral abdominal walls. Surgical repair included reduction of the liver and colon, reconstruction of the diaphragm, and mesh implantation. Postoperative course was uneventful and without recurrence (9 mo postoperatively).

Figure 1.

(A–C) Chest computed tomography imaging demonstrated a large, complex right lateral transdiaphragmatic intercostal hernia between the 9th and 10th ribs, with herniation of the liver and gallbladder. (D) There was also herniation of the cecum and terminal ileum through a large ventral hernia into the subcutaneous tissue.

TDIH is an uncommon event, primarily reported after blunt or penetrating injury to the diaphragmatic and intercostal muscles. The herniated abdominal contents most often include the stomach, small bowel, spleen, colon, omentum, and rarely, the liver (1–3). Associated symptoms of chest wall and flank pain, dyspnea, a reducible mass along the lower chest wall, and localized ecchymosis from intercostal muscle rupture may develop acutely or slowly progress. Computed tomography imaging is preferred for diagnostic confirmation and permits presurgical assessment. Progressive, symptomatic, or large defects should be managed surgically.

Cough as the precipitating event for TDIH of the liver is extremely rare. In all prior reports, patients had multiple predisposing factors, such as obstructive lung disease, diabetes, obesity, advanced age, and/or chronic steroid use (4, 5). Aside from age and obesity, our patient had no predisposing illness or trauma and no clinical evidence of connective tissue disease. Although rare, posttussive TDIH of the liver should be considered in those with flank pain and a reducible, palpable mass after violent coughing episodes.