This is a 26‐year‐old white male who presented to the emergency department with chest pain for 4 days. He described the pain as dull, achy, and located over the left chest. The pain was 6/10 in severity, nonradiating, and associated with mild dyspnea and productive cough. He denied fever or chills. He also had had crampy abdominal pain, nausea, and vomiting over the past week. He was seen in another emergency department 10 days ago and had a normal chest x‐ray. Past medical history includes stab wound to the left chest 1½ years ago that did not require any surgical therapy. Vital signs were temperature 36.2, blood pressure 135/60, heart rate 125, respiratory rate 22, and pulse‐ox of 95% on room air. General examination revealed an ill‐appearing, diaphoretic male. Neck exam indicated no jugular venous distention. Heart sounds were normal. Lung exam indicated decreased breath sounds on the left and clear lung sounds on the right. No rales, rhonchi, or wheezing were present. Abdomen exam was unremarkable. Laboratory studies indicated a normal CBC, troponin, and electrolytes. A chest x‐ray was performed That indicated bowel loops present in the left mid‐ and lower lung consistent with a diaphragmatic hernia. CT chest indicated left diaphragmatic hernia with edema around the bowel wall.
Diaphragmatic hernia is the protrusion of an abdominal organ through the wall that normally contains it, allowing it to migrate into the chest cavity. Diaphragmatic hernias usually result from a weakness in the muscle tissue at the esophagus opening. This weakness could be congenital or develop over Time because of excessive weight gain, pregnancy, heavy lifting, or intense coughing. Most diaphragmatic hernias are congenital and detected in neonates at birth. In adults, the causes of a diaphragmatic hernia are trauma, neurologic, iatrogenic, and spontaneous. Trauma accounts for the majority of diaphragmatic hernias in adults and has an incidence of 0.8% in blunt trauma. In this case, the patient denied any recent trauma and had a normal chest x‐ray 10 days prior to presentation. Patient also denied any abdominal surgery that could result in phrenic nerve injury, causing diaphragmatic hernia. Therefore, we concluded That this patient has a spontaneous diaphragmatic hernia. Spontaneous diaphragmatic hernias are extremely rare. Most patients are asymptomatic unless the diaphragmatic hernia becomes incarcerated. Symptoms include severe chest pain, exertional dyspnea, orthopnea, respiratory distress, bloating, difficulty swallowing, and abdominal pain. The treatment for diaphragmatic hernias requires surgery. The patient underwent for emergent surgery to relieve the incarcerated bowel and had an uneventful hospital course.
This case demonstrates a rare, unusual case of a spontaneous diaphragmatic hernia in an adult. In any patient presenting with recurrent chest pain, it is necessary to remain vigilant for atypical causes of chest pain and consider ordering a chest x‐ray.
T. Kanluen, none.