Diagnosis

Congenital diaphragmatic hernia.

Findings

Examination of the initial chest film demonstrates multiple loops of herniated bowel in the patient's left chest cavity. This is causing significant mass-effect with associated rightward mediastinal shift. Following repair there is residual mediastinal shift. In addition, a small hypoplastic left lung is seen.

Discussion

Congenital diaphragmatic hernias are secondary to diaphragmatic weakness. This is classically posterior i.e Bochdalek hernia. The hernias themselves are more common on the left (5:1). This is thought to be secondary to the presence of the liver. Patient's with diaphragmatic hernia generally present with respiratory distress. The radiographic appearance depends on the quantity of air within the herniated viscera. The initial exam may be radiopaque as no air has entered the bowel. Once air is introduced into the bowel, air-filled viscera that extends from the abdomen into the chest cavity is diagnostic. In questionable cases a NG tube can be inserted to confirm the diagnosis. The herniated contents will cause hypoplasia of the patient's lungs secondary to compressive effect. The patient's mortality rate is directly related to the degree of pulmonary hypoplasia. Poor prognostic indicators are lack of aerated ipsilateral lung, severe mediastinal shift and poor aeration in the contralateral lung.

Donnelly, Lane F. Fundamentals of Pediatric Radiology W B Saunders Co; March 9, 2001