Case Presentation: A 71-year-old woman presented to the hospital after her granddaughter noticed two days of worsening jaundice. The patient reported a one-week history of fatigue, early satiety, poor appetite, nausea, and vomiting. She also noted having tea-colored urine and a 30-pound unintentional weight loss during the previous eight months. She denied history of trauma, recent surgery, abdominal pain, fever, or chills.
Upon admission, the patient was noted to be diffusely jaundiced over her entire body. Her liver function tests were elevated, and abdominal ultrasound demonstrated a mildly dilated common bile duct at 8mm, as well as intrahepatic ductal dilation. Magnetic resonance cholangiopancreatography (MRCP) demonstrated stomach, pancreas, small bowel and most of the colon to be above the diaphragm with abnormal orientation of the extrahepatic bile ducts extending superiorly to the duodenum located in the thorax. Computed tomography (CT) of thorax, abdomen, and pelvis revealed a large diaphragmatic hernia, and it confirmed presence of pancreas, small bowel, and colon in the thorax.

Surgical repair of the defect was considered, however, due to the patient’s poor functional status, the risks of surgery were determined to outweigh the benefits. Biliary decompression with stent placement was performed instead. This was accomplished percutaneously, as her anatomy was not amenable to an endoscopic approach. She tolerated the procedure well, and her jaundice and transaminitis subsequently resolved. Plan was made for stent replacement as needed for recurrence of jaundice.

Discussion: Diaphragmatic hernias (DH) can be congenital or traumatic. The vast majority of congenital diaphragmatic hernias (CHD) present in infancy or childhood and occur at a rate of less than 5 per 10,000 live births. The incidence of CDH found incidentally on CT in adults is 0.17%, but the incidence of CHD leading to clinical presentation has not been reported. While several case reports of congenital DH causing obstructive jaundice can be found in the pediatric literature, only two published cases could be located describing this phenomenon in adults. One case was reported in a 19-year-old female and the other was reported in a 64-year-old female.

Our patient reported no history of trauma therefore, her diaphragmatic hernia was presumed to be congenital. The treatment of choice is surgical correction of the hernia to decompress biliary obstruction while preventing bowel obstruction or ischemia and lung injuries.

Conclusions: Painless jaundice with early satiety and weight loss in the elderly is a concern for biliary obstruction due to neoplasm. These signs and symptoms may also be caused by compression of the bile duct due to complication from a diaphragmatic hernia. Therefore, clinicians should consider an anatomic anomaly in the differential diagnoses of a patient with new onset jaundice.