Bochdalek Hernia with Gastric Necrosis in a 54-Year-Old Man, Case Report and Review of the Literature

Background: Bochdalek hernia is a very rare pathology with predominant presentation in newborns, manifested with respiratory distress secondary to pulmonary hypoplasia. The presentation in adults is even rarer, with some reported cases in the context of gastrointestinal complications or incidentally diagnosed, with high morbidity and mortality associated. Case: A 54-year-old male presented at emergency room with respiratory distress. He had pathological background including Diabetes Mellitus 2 diagnosed 2 years ago without control and alcoholism. He was drinking alcohol last two days. He presented feeding intolerance and vomiting last two hours associated with respiratory distress. At physical exam with Glasgow 15, not cooperative for respiratory distress, 110 beat per minute, 30 breaths per minute, without ventilation in left hemi-thorax and SO2 80%. Abdomen without hematomas or other superficial lesions, without acute abdomen signs but a correct evaluation can’t be accomplished by lack of cooperation secondary to respiratory insufficiency. Emergency Department suspected tension pneumothorax and practice a thoracic decompression by puncture obtaining 60cc of blood and intestinal material. An X-ray revealed a gastric bubble in left hemi-thorax. Emergency laparotomy was developed finding a left postero-lateral diaphragmatic hernia with 9 cm of diameter, 300cc intestinal liquid and gastric necrosis in 90% with body perforation by previous punction, without reperfusion after reduction. Subtotal gastrectomy and Y-Roux gastro jejunum anastomosis and diaphragmatic hernioplasty without mesh was developed. After 7 days in Intensive Care Unit with septic shock patient present pneumonia and died 7 days later. Conclusion: Bochdalek hernia in adults is a very rare pathology that must be corrected immediately after diagnosis by the high rate of associated complications as in the presented case, including advanced procedures like gastro-intestinal resections, with a high morbidity and mortality. When abdominal compromise is suspected an abdominal approach must be preferred to correct the diaphragmatic hernia and the possible lesions associated.