2019 Research Forum

Adria Ottoboni 1 MD, Larissa Morsky 2 MD R3, Laura Castro 3 RA, Mark Rhoades 3 RA 1 Faculty, Emergency Medicine 2 PGY-III, Emergency Medicine 3 Research Associate, Emergency Medicine Research Associate Program Acquired Pediatric Right Diaphragmatic Hernia Following AICD Placement

A 1-year-old male with a past medical history of prolonged QT syndrome and past surgical history of a sternotomy with an implantable cardioverter-defibrillator (ICD) and pacemaker placements presented to the emergency department in moderate respiratory distress with tachypnea, nasal flaring and subcostal retractions. The father reported that the patient had been irritable, coughing, vomiting, and diaphoretic over the past day. Case Presentation Visual Case Discussion Chest radiograph demonstrated infiltrate vs. atelectasis in the right lung base with a large right-sided diaphragmatic hernia. Consolidation was seen in the right lower lobe with infiltration of the large colon into the right hemi-thorax with apparent bowel gas in the chest cavity ( Image 1 ). Chest x-ray from six months prior showed no evidence of diaphragmatic hernia. ( Image 2 ). During operative intervention findings included bowel, colon, and omentum herniation through the anterior subxiphoid region through the right-sided diaphragmatic defect, with the liver pushed posteriorly. The pacemaker coil leads were wrapped within this hernia.

Case Imaging

Discussion In this

case, the right-sided diaphragmatic hernia was likely a sequelae of the initial surgical placement of the AICD. As seen on chest radiograph ( Image 3 ) from approximately one month prior to presentation in the emergency department, the diaphragmatic hernia slowly increased in size, eventually causing respiratory distress and V/Q mismatch. This manifested as an increased respiratory rate, evidence of auto-peep and feeding difficulties. Given that right-sided diaphragmatic hernias are rare in children and do not have a specific clinical presentation, the clinician should consider the possibility of diaphragmatic hernia in a child presenting with respiratory distress or signs of gastrointestinal obstruction, especially those with prior abdominal or thoracic surgery. 1,2 The patient should be radiographically examined quickly upon presentation to avoid the morbidity and mortality associated with delayed diagnosis and management. 1,2

Image 1 . AP chest x-ray performed on date of presentation to the ED in respiratory distress demonstrating significant elevation of the right hemidiaphragm with colonic interposition and right lung base infiltrate.

Image 3 . AP chest x-ray 1 month prior to Image 1, demonstrating right colonic interposition with probable associated atelectasis.

Image 2 . AP chest x-ray which demonstrates prior sternotomy without any elevation of the diaphragm.

1. El-Gohary Y, Schuster I, Scriven RJ, et al. Iatrogenic diaphragmatic hernia in infants: Potentially catastrophic when overlooked. J Pediatr Surg Case Rep . 2014;2(11):515-8 2. Wang K, Gao W, Ma N, et al. Acquired diaphragmatic hernia in pediatrics after living donor liver transplantation: Three cases report and review of literature. Med . 2018;97(15) References

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