Tariq Burki, Amir Amanullah, Atta Ur Rehman, Mian Naushad Ali.
Late presentation of Bochdalek hernia with intestinal symptoms.
J Ayub Med Coll Abottabad Jan ;14(3):27-8.

A 15 years old boy presented to the medical out patient department with complaints of cough, vomiting and abdominal pain for one month. He also had constipation and abdominal distension for three days. The vomiting was non bilious and after every meal. Examination showed a thin lean boy with scaphoid abdomen, normal bowel sounds and decreased breath sounds over the left side of the chest. The X-ray showed left pleural effusion. The differential diagnosis included Pulmonary TB, abdominal Koch with sub acute intestinal obstruction. Surgical consultation was made for intestinal obstruction. In the surgical ward X-Rays were viewed with suspicion of diaphragmatic hernia. Detailed history revealed that he had on and off symptoms of sub acute intestinal obstruction since three years of age. He had no respiratory symptoms at all. Examination revealed scaphoid abdomen with bowel sounds in the left hemithorax. Barium meal and follow through confirmed left side diaphragmatic hernia. Peroperatively there was a large postereolateral diaphragmatic defect through which most of the small and large intestine and spleen had herniated into the left chest. There was also malrotation of gut with bands of Ladd giving rise to obstructive symptoms and a large stomach. The contents were reduced and the defect repaired with silk. Malrotation was also corrected at the same time. Although there was some difficulty in closing the abdomen, the patient had an uneventful recovery in ICU. Post-operative X-Ray after one week showed remarkable lung expansion.

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