indzun ~, Pediatr. 44 : 322, 1977
RIGHT SIDED CONGENITAL DIAPHRAGMATIC
HERNIA
BHARAT PRASAD SINGrt, P. KU.~AR AND SUISHUPAU RA,X~ Patna
The normal diaphragm provides a complete muscular partition between the thoracic and abdominal cavities. Communication between these two cavities may result from an i~complete congenital or acquired detect of the d i a p h r a g m . Diaphragmatic hernia m a y be traumatic or non-traumatic. Congenital hernias are the result of incomplete development and usually lack a hernial sac. T h e herniation m a y occur through the oesophageal hiatus, through the foramen of Morgagni, through the foramen of Bochdalek or through a partial absence of the diaphragm. Report of a Case
S.K., a l-year-6-month-old child ,xas admitted to the Children Medical w a r d of the Patna Medical College Hospital on 27th August 1972 for the treatment of recurrent cough and vomiting since early infancy. He was normal at birth but developed recurrent attacks of cough and breathlessness and was treated for pertusiss for a long time. Clinical e x a m i n a t i o n revealed an undernourished, pale and anxious child with hurried respiration. Cyanosis was absent at the time of admission. Physical examination showed basal dullness with diminished air entry over the right side of the chest. T h e trachea and apex beat were in the normal position. Vocal fremitus and vocal resonance were diminished on the right *From the Department of Paediatrics, Patna Medical College Hospital, Patna. Received on March 17, 1977.
base. Other systems did not reveal any positive finding except that the liver was palpable 2 cm below the right costal margin. X-ray of the chest, P.A. view, showed gas bubbles in the right chest at its base and lower zone (Fig. 1, Plate I). A provisional diagnosis ot right sided diaphragmatic hernia was made, subsequently confirmed by a barium meal which showed loops of gut tilled with barium in the right thoracic cavity (Fig. 2, Plate I). The patient was then sent for surgical consultation. Discussion
The incidence of congenital diaphragmatic hernia is one in 1250 to 2500 births (Rikhy etal. 1963). The occurrence of bilateral congenital diaphragmatic hernia is extremely rare. A review of the available literature has shown only nine cases of bilateral congenital hernias (Bowers et al. 1955, Butler a n d Claireaux 1962): The aetiology of different types of diaphragmatic hernia has been discussed by various workers (Ringler and Eneboe 1935, Allison 1962). Some of rhem have advocated a genetic theory as a cause of congenital diaphragmat[c hernia. Recently, Kassem etal. (1965) have proposed a hypothesis that kyphoscoliosis may be responsible for the causation of congenital diaphragmatic hernia by increasing abdominal pressure or by diminishing abdominal space or both which will favour the displacement of the abdominal contents into the thorax. Congenital absence of a h e m i - d i a p h r a g m is a
S1NGtl /.2T AI..--RIGHT SIDED CON(;F.N1TAL DIAPHRA(-;MATICHERNIA
32'.3
r a r e a n a t o m i c a l a b n o r m a l i t y a n d occurs u s u a l l y on the left side. B e n j a m i n (1963) r e p o r t e d ten cases o f a b s e n c e of a hemi-
T h e onset o f s y m p t o m s is not d r a m a t i c in o l d e r c h i l d r e n h a v i n g d i a p h r a g m a t i c hernia. Physical signs in tile chest a r e
d i a p h r a g m in a t h r e e - y e a r survey. R i g h t sided d i a p h r a g m a t i c h e r n i a is a r a r i t y in p a e d i a l r i c p r a c t i c e . H a r r i n g t o n (1943) o p e r a t e d u p o n 404 cases o f d i a p h r a g m a t i c h e i n i a ; out Of these r i g h t sided h e r n i a was p r e s e n t in only one case. I n an a u t o p s y study, C a r t e r et al. (1962) r e p o r t e d five cases o f right sided d i a p h r a g m a t i c h e r n i a out o f
often so confusing that t h e diagnosis m a y be missed if a n X - r a y is not taken a n d r e a d carefully.
27 neonates.
V a r e (1972) r e p o r t e d on case
of right sided d i a p h r a g m a t i c h e r n i a out o f five in a n o t h e r a u t o p s y study. T h e i n c r e a s e d i n c i d e n c e o f left sided lesions has been a s c r i b e d to late closure of the left p l e u r o p e r i t o n e a l c a n a l , a l l o w i n g the intestine which h~ad r e c e n t l y become i n t r a - a b d o m i n a l , to h e r n i a t e t h r o u g h the defect.
Summary A n unusua! case o f right s i d e d d i a p h r a g m a t i c h e r n i a has b e e n p r e s e n t e d w i t h a brief r e v i e w of th( l i t e r a t u r e . T h e s y m p t o m s of c o n g e n i t a l d i a p h r a g m a t i c h e r n i a v a r y a g r e a t deal. T h e y m a y be e i t h e r c a r d i a c , r e s F i r a t o r y , g a s t r o i n t e s t i n a l or a c o m b i n a t i o n o f all three.
References Allison, P.R. (1962). Quoted by Vare, A.M, (1972). Indian J. Paediatr. 39, 165. Benjamin, H B. (1963). A genetis of left hemldiaphragm. Thor Cardiovasc. Surg. 46,265. Bowers et al. (1955b Diaphragmatic hernia in new born. Obst. & Gynec. 6, 22. Butler, N. and Claireaux, A.E. (1962). Congenital diaphragmatic hernia as a cause of peri-natal mortality. Lancet, 1,659, Carter, R.E B. Waterston, D.J. and Aberdeen, E. (1962). Hernia and. eventration of the diaphragm in chidren. Lancet, 1, 656. Harrington, S.W. (1945). Surgical treatment of more common types of diaphragmatic hernia. Ann. Surg. 122,546. Kassem, N.Y., Groven, J . J . and Fraenkeel. (1965). Spinal deformities and oesophageal hiatus hernia. Lancet, 1,887. Rikhy, S.S. et al. (lg63). Congenital diaphragmatic hernia. Indian 07. Chld. Hlth. 12, 456. Ringler, L.G. and Eneboe, J.B. (1935). Quoted by Kassem et al. (1965). Vare, A.M. (1972). Congenital diaphragmatic hernia. Indian .], Paediatr. 39, 165.
RIGHT SIDED CONGENITAL DIAPHRAGMATIC
HERNIA
BHARAT PRASAD SINGrt, P. KU.~AR AND SUISHUPAU RA,X~ Patna
The normal diaphragm provides a complete muscular partition between the thoracic and abdominal cavities. Communication between these two cavities may result from an i~complete congenital or acquired detect of the d i a p h r a g m . Diaphragmatic hernia m a y be traumatic or non-traumatic. Congenital hernias are the result of incomplete development and usually lack a hernial sac. T h e herniation m a y occur through the oesophageal hiatus, through the foramen of Morgagni, through the foramen of Bochdalek or through a partial absence of the diaphragm. Report of a Case
S.K., a l-year-6-month-old child ,xas admitted to the Children Medical w a r d of the Patna Medical College Hospital on 27th August 1972 for the treatment of recurrent cough and vomiting since early infancy. He was normal at birth but developed recurrent attacks of cough and breathlessness and was treated for pertusiss for a long time. Clinical e x a m i n a t i o n revealed an undernourished, pale and anxious child with hurried respiration. Cyanosis was absent at the time of admission. Physical examination showed basal dullness with diminished air entry over the right side of the chest. T h e trachea and apex beat were in the normal position. Vocal fremitus and vocal resonance were diminished on the right *From the Department of Paediatrics, Patna Medical College Hospital, Patna. Received on March 17, 1977.
base. Other systems did not reveal any positive finding except that the liver was palpable 2 cm below the right costal margin. X-ray of the chest, P.A. view, showed gas bubbles in the right chest at its base and lower zone (Fig. 1, Plate I). A provisional diagnosis ot right sided diaphragmatic hernia was made, subsequently confirmed by a barium meal which showed loops of gut tilled with barium in the right thoracic cavity (Fig. 2, Plate I). The patient was then sent for surgical consultation. Discussion
The incidence of congenital diaphragmatic hernia is one in 1250 to 2500 births (Rikhy etal. 1963). The occurrence of bilateral congenital diaphragmatic hernia is extremely rare. A review of the available literature has shown only nine cases of bilateral congenital hernias (Bowers et al. 1955, Butler a n d Claireaux 1962): The aetiology of different types of diaphragmatic hernia has been discussed by various workers (Ringler and Eneboe 1935, Allison 1962). Some of rhem have advocated a genetic theory as a cause of congenital diaphragmat[c hernia. Recently, Kassem etal. (1965) have proposed a hypothesis that kyphoscoliosis may be responsible for the causation of congenital diaphragmatic hernia by increasing abdominal pressure or by diminishing abdominal space or both which will favour the displacement of the abdominal contents into the thorax. Congenital absence of a h e m i - d i a p h r a g m is a
S1NGtl /.2T AI..--RIGHT SIDED CON(;F.N1TAL DIAPHRA(-;MATICHERNIA
32'.3
r a r e a n a t o m i c a l a b n o r m a l i t y a n d occurs u s u a l l y on the left side. B e n j a m i n (1963) r e p o r t e d ten cases o f a b s e n c e of a hemi-
T h e onset o f s y m p t o m s is not d r a m a t i c in o l d e r c h i l d r e n h a v i n g d i a p h r a g m a t i c hernia. Physical signs in tile chest a r e
d i a p h r a g m in a t h r e e - y e a r survey. R i g h t sided d i a p h r a g m a t i c h e r n i a is a r a r i t y in p a e d i a l r i c p r a c t i c e . H a r r i n g t o n (1943) o p e r a t e d u p o n 404 cases o f d i a p h r a g m a t i c h e i n i a ; out Of these r i g h t sided h e r n i a was p r e s e n t in only one case. I n an a u t o p s y study, C a r t e r et al. (1962) r e p o r t e d five cases o f right sided d i a p h r a g m a t i c h e r n i a out o f
often so confusing that t h e diagnosis m a y be missed if a n X - r a y is not taken a n d r e a d carefully.
27 neonates.
V a r e (1972) r e p o r t e d on case
of right sided d i a p h r a g m a t i c h e r n i a out o f five in a n o t h e r a u t o p s y study. T h e i n c r e a s e d i n c i d e n c e o f left sided lesions has been a s c r i b e d to late closure of the left p l e u r o p e r i t o n e a l c a n a l , a l l o w i n g the intestine which h~ad r e c e n t l y become i n t r a - a b d o m i n a l , to h e r n i a t e t h r o u g h the defect.
Summary A n unusua! case o f right s i d e d d i a p h r a g m a t i c h e r n i a has b e e n p r e s e n t e d w i t h a brief r e v i e w of th( l i t e r a t u r e . T h e s y m p t o m s of c o n g e n i t a l d i a p h r a g m a t i c h e r n i a v a r y a g r e a t deal. T h e y m a y be e i t h e r c a r d i a c , r e s F i r a t o r y , g a s t r o i n t e s t i n a l or a c o m b i n a t i o n o f all three.
References Allison, P.R. (1962). Quoted by Vare, A.M, (1972). Indian J. Paediatr. 39, 165. Benjamin, H B. (1963). A genetis of left hemldiaphragm. Thor Cardiovasc. Surg. 46,265. Bowers et al. (1955b Diaphragmatic hernia in new born. Obst. & Gynec. 6, 22. Butler, N. and Claireaux, A.E. (1962). Congenital diaphragmatic hernia as a cause of peri-natal mortality. Lancet, 1,659, Carter, R.E B. Waterston, D.J. and Aberdeen, E. (1962). Hernia and. eventration of the diaphragm in chidren. Lancet, 1, 656. Harrington, S.W. (1945). Surgical treatment of more common types of diaphragmatic hernia. Ann. Surg. 122,546. Kassem, N.Y., Groven, J . J . and Fraenkeel. (1965). Spinal deformities and oesophageal hiatus hernia. Lancet, 1,887. Rikhy, S.S. et al. (lg63). Congenital diaphragmatic hernia. Indian 07. Chld. Hlth. 12, 456. Ringler, L.G. and Eneboe, J.B. (1935). Quoted by Kassem et al. (1965). Vare, A.M. (1972). Congenital diaphragmatic hernia. Indian .], Paediatr. 39, 165.
