A two year old child presented with acute onset respiratory distress with multiple episodes of non-bilious vomiting. Chest X-ray of the child at the time of presentation showed free air in the left pleural cavity displacing the trachea and the mediastinum grossly to the opposite side, compressing the right lung as well. The X-ray looked very classical of a left sided tension pneumothorax, but a closer look was making things suspicious, so CT scan of the chest was done. To our surprise, it turned out to be a case of left sided congenital diaphragmatic hernia, with the distally obstructed stomach dilating severely to cause the large air shadow and displacing the mediastinum. Spleen, transverse colon and small bowel loops were also visualized in the left hemithorax. Putting a Ryle’s tube decompressed the stomach and respiratory distress was resolved. Patient was planned and then taken for surgery, intraoperatively, it was a classical Bochdalek hernia with a narrow defect in the posterolateral aspect of left dome of diaphragm, leading to compression and obstruction at the level of pylorus. All the contents were reduced and primary repair of the defect was done. Postoperative X-ray showed nicely expanded left lung with return of the mediastinum to the normal position with well-maintained left dome of diaphragm. The child was discharged uneventfully.
Congenital diaphragmatic hernia is a birth defect with an incidence of about 1 per 5000 live births, where there is a defect in the sheet of muscle (diaphragm) separating the abdomen from the chest, as a result the contents of the abdomen enter into the chest cavity and start compromising the lung causing difficulty in breathing. This happens more commonly on the left side as seen in this case.
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