대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesArchive of Old Cases

Case No : 1414 Date 2024-11-26

  • Courtesy of Kwang Nam Jin / Sangheum, Bang / Moon Young Kim / SMG-SNU Boramae Medical Center
  • Age/Sex 67 / M
  • Chief ComplaintChief complaint> abrupt onset of chest pain and dyspnea ............. Underlying disease> None
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7

Diagnosis With Brief Discussion

Diagnosis
Pneumothorax in patient with diaphragmatic herniation
Radiologic Findings
Initial chest radiograph showed right pneumothorax and collapsed right lung (Fig. 1A). The Right pneumothorax resolved after placing the right chest tube (Fig. 1B). Incidentally, CT demonstrated the gas-distended colon loop around the proximal portion of the right chest tube (Fig. 2A, B). CT coronal image demonstrates focal discontinuation of the right diaphragm and herniation of the colon, omental fat, and liver. It revealed that the air densities around the herniated abdominal contents are in the thoracic cavity, not in the abdominal cavity (Fig. 3, 4).
Brief Review
• Video-assisted thoracoscopic surgery (VATS) was done for a wedge resection of bullae in the right lung with a demonstration of a 10 cm by 5 cm sized diaphragmatic defect, which cannot be repaired due to its large size (Figure 5). After surgery, the symptoms resolved, and the follow-up radiograph showed a complete resolution of pneumothorax.

• Pneumothorax and diaphragmatic hernia is an unusual combination. Incidentally detected diaphragmatic defects have been reported in variable clinical settings [1-5]. Pneumoperitoneum noted after the chest tube insertion for pneumothorax could be a critical finding, suggesting diaphragmatic injury. However, identifying diaphragmatic discontinuation and herniation of the colon and the unusual protruding shape of the liver dome led to the radiologic diagnosis of an unrelated diaphragmatic herniation. The probable etiology of the diaphragmatic herniation is old blunt trauma or congenital defect in this case. However, there is no related medical history.
References
[1] Blitz M, Louie BE. Chronic traumatic diaphragmatic hernia. Thorac Surg Clin. 2009;19:491-500.
[2] Gu P, Lu Y, Li X, Lin X. Acute and chronic traumatic diaphragmatic hernia: 10 years’ experience. PLOS ONE. 2019;14:.
[3] Soro J, Blanco M, García-Fontán E. Pneumothorax and Congenital Diaphragmatic Hernia: An Unusual Combination. Arch Bronconeumol. 2015;51;655
[4] Polat N, Kesici U, Kesici S, Yılbaş S. Morgagni hernia detected due to pneumothorax development during diagnostic colonoscopy. Turk J Gastroenterol. 2014;25:448-9.
[5] Kesavaramanujam S, Morell MC, Harigovind D, Bhimmanapalli C, Cassaro S. Total thoracic herniation of the liver: a case of delayed right-sided diaphragmatic hernia after blunt trauma. Surg Case Rep. 2020;22:178.
Keywords

No. of Applicants : 58

▶ Correct Answer : 6/58,  10.3%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - University of Yamanashi , Japan HIROYUKI MORISAKA
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - Matsunami General Hospital , Japan TARO TAKEDA
▶ Correct Answer as Differential Diagnosis : 3/58,  5.2%
  • - , Japan SUZUNE TSUKAMOTO
  • - , Japan YOSHIKI ISHII
  • - , Japan SHUHEI NORIMOTO
▶ Semi-Correct Answer : 28/58,  48.3%
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - Oita university , Japan AYUMI KAMEI
  • - Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
  • - IRSA LA ROCHELLE , France JEAN LUC BIGOT
  • - , Korea (South) DONG-HO BANG
  • - Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
  • - Other , Korea (South) SEONGSU KANG
  • - , Korea (South) JIN YOUNG LEE
  • - Other , Korea (South) DOWOO KIM
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - University of Yamanashi , Japan TAKAAKI HASHIMOTO
  • - University of Yamanashi , Japan HIROAKI WATANABE
  • - Nankai medical center , Japan NORITAKA KAMEI
  • - Other , Korea (South) CHAEHUN LIM
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Shiga General Hospital , Japan YUSAKU MORIBATA
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - Mie university , Japan SHIKO OKABE
  • - The First Affiliated Hospital of Nanjing Medical University , China TENG ZHANG
  • - Kyoto University , Japan SHO KOYASU
  • - , India GOMATHIPONSHANKAR ILAYAPPAN
  • - Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
  • - Fukuoka university , Japan KEISUKE SATO
  • - The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
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