RGUHS Nat. J. Pub. Heal. Sci Vol: 14 Issue: 4 eISSN: pISSN
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1Dr. Vinod Uplonkar, Faculty of Medical Sciences, Khaja Banda Nawaz University, Kalaburagi, Karnataka, India.
2Faculty of Medical Sciences, Khaja Banda Nawaz University, Khaja Banda Nawaz University, Kalaburagi, Karnataka, India
3Faculty of Medical Sciences, Khaja Banda Nawaz University, Khaja Banda Nawaz University, Kalaburagi, Karnataka, India
4Faculty of Medical Sciences, Khaja Banda Nawaz University, Khaja Banda Nawaz University, Kalaburagi, Karnataka, India
*Corresponding Author:
Dr. Vinod Uplonkar, Faculty of Medical Sciences, Khaja Banda Nawaz University, Kalaburagi, Karnataka, India., Email: vinsadoc@gmail.com
Abstract
Congenital diaphragmatic hernia is a condition characterized by the herniation of abdominal contents into the chest, leading to respiratory distress shortly after birth. In the present case, along with bowel herniation, spleen herniation was also noted, which is a very rare occurrence. This case was diagnosed antenatally, and the diagnosis was further confirmed postnatally with a chest and abdominal X-ray, as well as a chest ultrasound. The baby was stabilized and shifted for surgical intervention, where the patient underwent a laparotomy, revealing a diaphragmatic defect with herniation of the ileum, colon and spleen. Surgically the defect was closed, and the bowel and spleen were reduced back into the abdomen for proper opening of the lung. No complications were noticed during the postoperative period. Therefore, we believe that this rare case of spleen herniation, which was managed promptly, as a valuable contribution to the existing literature.
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Introduction
Congenital diaphragmatic hernia (CDH) is a structural birth defect where the diaphragm fails to develop properly and completely. Its occurrence can be isolated or can present with additional anomalies. It is a multifactorial disease with the involvement of genetic factors that may result in a developmental delay, either directly or indirectly contributing to it. CDH has an estimated incidence of 1 in 1,750-5,880 live births.1 Up to 80% to 95% of cases are diagnosed with antenatal ultrasound.2,3 In humans, three different types of hernia can be distinguished: posterolateral, Bochdalek hernia (70%); Morgagni type (27%); central hernia, Septum transversum type (2%-3%).4
Case Report
This case report is about a term female baby with a gestation age of 38 weeks and a birth weight of 2.5 kg, born to a 21-year-old primi mother from a non consanguineous marriage by lower segment caesarean section at a private hospital. Left sided CDH was detected antenatally at 31.5 weeks of gestation. The baby cried immediately after birth and presented with respiratory distress, tachypnea, grunting, and subcostal indrawing. Baby was admitted immediately to Neonatal Intensive Care Unit (NICU) and was shifted to our center for surgery and further management. On examination, the infant was in respiratory distress, with a respiratory rate of 70 breaths per minute, a heart rate of 160 beats per minute, and a pulse oximetry reading of 80% on room air. Yellowish discoloration was observed on the palms and soles, along with subcostal and intercostal retractions. Decreased breath sounds were noted on the left side of the chest, and bowel sounds were present on the left. Heart sounds were heard on the right side of the thorax, and the abdomen appeared scaphoid. Baby was maintained on two liters oxygen. Chest X-ray was done which showed left sided congenital diaphragmatic hernia (Figure 1).
After stabilizing, the baby was scheduled for surgical repair. Following intubation, subcostal incision laparotomy was performed. The abdominal organs, stomach, intestine and spleen head were found herniated into the thoracic cavity, and were successfully restored back into the peritoneal cavity as shown in Figure 2.
The primary hernia repair was done with intercostal drain (ICD) insertion. The patient was shifted to NICU, self-extubated after six hours following surgery. The child maintained well on nasal prongs, with an uneventful postoperative hospital stay and was discharged on day 15. Following surgery, the infant had no further respiratory/ GI complications.
Discussion
Congenital diaphragmatic hernia is a rare but lethal anomaly. It is characterized by the herniation of abdominal organs into the pleural cavity, thus compressing the lungs and displacing the mediastinum to the opposite side.4 Mortality depends on factors such as associated malformations, the severity of pulmonary hypoplasia, pulmonary hypertension, and iatrogenic lung injury from aggressive mechanical ventilation. Additionally, the timing of surgery can impact mortality rates in high-risk congenital diaphragmatic hernia cases, with the practice of achieving clinical stability before surgery being widely adopted.5
Left sided CDH are common with a fairly good prognosis. Although the right sided CDHs are rare, they do have a good prognosis. The most common surgical challenges following initial repair are recurrent diaphragmatic hernia and small bowel obstruction. The overall recurrence rate is 15% in the first two years of life. Risk factors include large defect size, and need for a patch.6
Conflict of Interest
Nil
Supporting File
References
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