Dual diaphragmatic anomalies.

Although diaphragmatic anomalies such as an eventration and hiatus hernia are commonly encountered in incidental chest X-ray imaging, the presence of concomitant multiple anomalies is extremely rare. This is all the more true in adults. Herein, we present the case of a 75-year-old female, while undergoing a routine chest X-ray imaging, was found to have eventration of right hemidiaphragm along with a hiatus hernia as well.

THE CASE

A 75-year-old female presented to the chest clinic of our hospital with a history of a cough with mucoid expectoration, episodic dyspnea with wheeze of 1 month duration. She did not have any symptoms of chest pain, hemoptysis, recurrent fever, weight loss, reflux, or symptoms of postnasal drip. She had complaints of anorexia, abdominal bloating of 6 months duration. She did not give any past history of atopy or asthma, and her family history was also negative for same. General examination revealed that she had pallor. Systemic examination was unremarkable except for bilateral wheezes in the chest. Blood analysis showed a microcytic, hypochromic anemia. Differential cell count, hepatic, and renal functions were within normal limits. Electrocardiogram showed regular tracings. Her chest X-ray is shown in Figure 1. What is the abnormality seen?

Figure 1

Chest X-ray posteroanterior view showing elevated hemidiaphragm on the right, with a retrocardiac opacity on the left side

QUESTION

What is the diagnosis?

ANSWER

Eventration of the right hemidiaphragm and hiatus hernia.

DISCUSSION

Dual diaphragmatic anomalies are extremely uncommon. Diaphragmatic eventration is congenital in nature and is due to incomplete muscularization of the diaphragm with a thin membranous sheet replacing normal diaphragmatic muscle. Over a period of time, this region stretches and thins out, and on inspiration does not contract normally. Radiologically, elevation of the affected portion of the diaphragm is usually seen as a smooth hump, while the remainder of the hemidiaphragm contour is normal.[1] Hiatus hernias occur when there is a herniation of abdominal contents through the esophageal hiatus of the diaphragm into the thoracic cavity. There are two types of hiatus hernia-sliding and rolling type.[2]

Usually, both these defects are seen in isolation. However, combination of both an eventration and hiatus hernia occurring together is a very rare entity, and a thorough literature search showed only three previous such cases.[34] Almost all of them have been entirely described in pediatric population alone. Such cases are also predisposed to the development of gastric volvulus.[5] However, our patient did not have any radiological evidence of volvulus. The coronal reconstructed 64 slice computerized tomogram showed eventration of right hemidiaphragm with liver occupying the right lower hemithorax. Widening of the esophageal diaphragmatic hiatus with herniation of stomach and perigastric fat was also seen [Figure 2].

Figure 2

Coronal reconstructed 64 slice computed tomography image showing eventration of right hemidiaphragm with liver occupying the right lower hemithorax. Widening of the esophageal diaphragmatic hiatus with herniation of stomach and perigastric fat is also seen

Her spirometry showed a mild reversible airflow obstruction. She was managed conservatively considering her age and her respiratory symptoms resolved significantly after the institution of inhaled corticosteroids.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.