Obstructed Diaphragmatic Hernia in Children: Report of Two Cases

Emergency laparotomy was performed. There was a small gap in the left hemi diaphragm through which a loop of sigmoid colon was obstructed in the chest cavity. The neck of the hernia was incised to relieve the obstruction (Figure 2). There was an area of ischemic necrosis on the ant mesenteric border of obstructed sigmoid colon, which was repaired. Diaphragmatic hernia was repaired with nonabsorbable suture. Post operative x ray was grossly normal. The patient recovered well. Case Report


Introduction
Congenital diaphragmatic hernia (CDH) occurs in 1 per 2 to 5 thousand live births. Most cases of CDH present immediately after birth with respiratory symptoms. Only 10-20% patients present later with recurrent respiratory illness [1]. CDH presenting as intestinal obstruction in an older child is very rare [2,3]. We treated two patients of CDH presented with intestinal obstruction. A 6 year old previously asymptomatic girl presented with 2 days history of abdominal distention, bilious vomiting and constipation. General examination revealed mild dehydration and tachycardia.

Case 1
Abdomen was distended & tender with loud bowel sound. Rectum was empty. Provisional diagnosis was intestinal obstruction due to congenital bands. X ray abdomen in erect posture including chest revealed distended bowel loops with multiple air fluid level, bowel loops in left hemi thorax and heart pushed to right ( Figure  1). Other hematological and biochemical parameters were normal. Emergency laparotomy was performed. There was a small gap in the left hemi diaphragm through which a loop of sigmoid colon was obstructed in the chest cavity. The neck of the hernia was incised to relieve the obstruction (Figure 2). There was an area of ischemic necrosis on the ant mesenteric border of obstructed sigmoid colon, which was repaired. Diaphragmatic hernia was repaired with nonabsorbable suture. Post operative x ray was grossly normal. The patient recovered well.
A two year old boy presented with abdominal distension, vomiting & constipation. He had history of laparotomy and manual release of Intussusceptions at the age of 7 month. Physical examination revealed mild dehydration and tachycardia. Abdomen was distended, Bowel sound was present, rectum was empty. Provisional diagnosis was intestinal obstruction due to post operative band adhesion. X ray revealed intestinal obstruction with left sided diaphragmatic hernia (Figure 3). Abdomen was opened through left sub costal incision, diaphragmatic hernia with sac found (Figure 4). After reposition of gut hernia was repaired with non absorbable suture. Post operative period was uneventful.

Discussion
Causes of delayed presentation of CDH are either late rupture of small hernial sac or plugging of the hernial defect by solid viscera [2,4]. Only few authors reported intestinal symptoms in patients with diaphragmatic hernia. During our initial examination, we missed the respiratory findings of these patients as there were no respiratory complaints and this condition is not so common. Rawat et al. [5] have reported two children with CDH and intestinal obstruction, one in left side and another in right side. Koh et al. [6] reported a case of obstructed diaphragmatic hernia with transverse colon perforation. In our 1st case we found ischemic necrosis & perforation at sigmoid colon but gut was healthy in second case. In both cases narrow neck of the hernia was responsible for obstruction.
Horton et al. [3] reported two cases of obstructed hernia where stomach was the content. Burki et al. [7] also reported delayed presentation of Bochdalek hernia with intestinal symptoms. Alimoglu et al. [8] and Christianser et al. [9] reported strangulated diaphragmatic hernia following traumatic rupture of diaphragm. Both of our patients recovered well because pulmonary hypoplasia and hypertension are not prominent in older children with diaphragmatic hernia but delay in diagnosis may cause strangulation of intestine. Obstructed diaphragmatic hernia is a rare cause of intestinal obstruction in children. High index of suspicion is required for diagnosis and early diagnosis and management avoid intestinal complications. X ray is the primary and most important diagnostic tool.