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Hernia (2007) 11:377379 DOI 10.1007/s10029-007-0202-y
CASE REPORT
Mediastinal shift secondary to a diaphragmatic hernia: a life-threatening combination
A. S. Campbell M. E. ODonnell J. Lee
Received: 11 September 2006 / Accepted: 18 January 2007 / Published online: 13 February 2007 Springer-Verlag 2007
Abstract An 85-year-old man was referred to our department, with a three-day history of increasing shortness of breath. Following clinical and radiological assessment, diaphragmatic herniation of bowel was identiWed to be causing mediastinal shift and respiratory distress. An emergency laparotomy identiWed a massive diaphragmatic defect which was not amenable to primary closure. A colopexy procedure was performed to comparmentalise the abdomen and obliterate the diaphragmatic defect. Despite aggressive treatment in the intensive care unit he died from multi-organ failure. This case highlights an extremely rare and life-threatening cause of mediastinal shift and respiratory distress.
Keywords Mediastinal shift Diaphragmatic hernia
Operative repair
Introduction
We present a rare case of severe cardiorespiratory compromise and mediastinal shift secondary to a congenital diaphragmatic hernia. Mediastinal shift has been described with acquired hernias but rarely due to a congenital defect. This potentially life-threatening combination is often fatal and requires early diagnosis and prompt operative intervention.
Case report
The patient was an 85-year-old male who was admitted with a three-day history of increasing shortness of breath. He had a nonproductive cough with no other cardiorespiratory symptomatology. He also had a Wveday history of constipation and was noted to be more confused than normal. His past medical history included early dementia, a congenital diaphragmatic hernia and renal cell carcinoma, which were treated palliatively. The patient had no history of trauma. Previous elective repair of the diaphragmatic hernia was not considered due to a lack of cardiorespiratory symptomatology.
On examination his respiratory rate was 28 respirations/min, heart rate 150 beats/min, blood pressure 173/113 mmHg and temperature of 35.8C. Auscultation of his chest revealed reduced air entry on the right side with normal heart sounds. Abdominal examination revealed a soft, non-tender abdomen with associated tinkling bowel sounds and a large easily reducible left inguinal hernia. Chest X-ray demonstrated a dilated loop of bowel in the right hemithorax with mediastinal shift and compression of the left lung (Fig. 1). A subsequent arterial blood gas on 5 l/min oxygen supplementation conWrmed a decompensating respiratory...