Symptomatic Bochdalek Hernia in Adult

Luis Eduardo Almeida de Souza1, Karlla Lorenna dos Santos Anjos2, Danielle Oliveira de Sousa2, Gabriel de Jesus da Fonseca Loureiro2, Deborah Marques Centeno2, Yana Cardoso de Lima3, Rodrigo da Silva Cordeiro2, Felipe Teixeira Lisboa2, João Paulo da Silva Machado2, Karen Giovana Leal Matos2, Mauro Carvalho Vieira1 1 Hospital Porto Dias. Belém, Pará, Brazil. 2 Universidade do Estado do Pará. Belém, Pará, Brazil. 3 Instituto de Ciências da Saúde da Universidade Federal do Pará. Belém, Pará, Brazil.


Introduction
The Bochdalek hernia (HB) is a congenital defect located in the posterolateral diaphragm portion due to incomplete obliteration of the foramen situated in this region.It was first described by the anatomy professor Bochdalek in 1848 [1].The defect is extremely rare, with an estimated incidence in one case every 2,200-12,500 live births [2].
A wide range of complications related to Bochdalek hernia have been reported, including migration of the stomach, intestines, gallbladder, liver and spleen [3].Late presentation of HB is uncommon, occurring on the left portion of diaphragm in 88-97% of cases [4].They are usually asymptomatic when diagnosed in the adult, being an element of casual finding in a chest x-ray performed for another reason [5].
The aim of the present study is to report the case of late presentation of Bochdalek hernia in the left portion of diaphragm, in a symptomatic adult patient.Due to its clinical complications, it should be included among the differential radiological diagnosis.

Case report
Patient is male, 57 years old, sought the Hospital Porto Dias, Belém, Pará, Brazil, for the accomplishment of Chest Computed Tomography (CT).Asked about the indication of the exam, the patient reported dyspnea and long-standing postprandial epigastralgia, refractory to pharmacological treatment, but with spontaneous improvement after a few hours.While the patient was being examined, the presence of abdominal organs were observed in the posterior portion of the left phrenic hemicupula.
After the end of CT, the patient was questioned prior history of chest or abdominal trauma and previous surgeries, and denied any antecedent.Correlating its clinical history with the imaging findings, it was diagnosed Bochdalek's Hernia (HB) and suggested in the report the referral to the surgical service, to reduce the hernia.

Discussion
Bochdalek hernia is rare in adults and accounts for 0.17-6% of all diaphragmatic hernias.It is predominant in women and in the left diaphragm portion [6], being in this case, reported to the left, but in a symptomatic man.The diagnosis of Bochdalek hernia in adults is difficult, since many patients are asymptomatic.Therefore, there is an underdiagnosis [7].
Most congenital BHs are associated with respiratory insufficiency [8] that becomes evident during the first weeks of life, being among the most frequent causes of respiratory distress in neonates.As in adults, most BHs are usually asymptomatic, their detection is incidental [9].Symptoms, if any, are typically imprecise.Patients usually report chest pain or gastrointestinal symptoms [10], as the patient in this case, who reported complaints of postprandial epigastralgia refractory to pharmacological treatment, and dyspnea.It could often lead to a wrong diagnosis.Surgical treatment is necessary due to the complication range related to this hernia type, which, although often asymptomatic, may lead to tissue strangulation [10], pneumothorax and intestinal necrosis [11].

Conclusion
Bochdalek hernias are extremely rare in adults, presenting asymptomatic or non-specific symptoms, which make their diagnosis difficult to suspect.The importance of the recognition of its diagnosis, which must be among the differential diagnosis in radiology, is crucial because of the complication range related to this pathology.The Bochdalek Hernia treatment is surgical, aiming its reduction.The classic radiological examination with contrast and the computerized axial tomography confirms the diagnosis.
International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q2 in category Medicine.

Figure 1 :
Figure 1: Chest CT scan showing mesenteric fat, left kidney, splenic angle of the colon and part of the body/tail of the pancreas.Coronal and sagittal, respectively.