Challenge in managing a congenital strangulated Bochdalek Hernia in an elderly woman in a low-income country: A Case Report

Abstract

Introduction: Bochdalek hernias are the most common congenital diaphragmatic hernias. It can remain asymptomatic throughout life. Occasionally, it is discovered during complications such as respiratory distress due to strangulation or volvulus of herniated organs, with a late diagnosis due to its rarity in elderly individuals. It is an emergency condition that needs early diagnosis, treatment, and strong supportive care to save a patient's life. In this study, we discuss the specific challenges encountered in managing a congenital strangulated Bochdalek hernia in an elderly woman in our tertiary health center. Case presentation: We report the case of an 88-year-old black woman admitted in October 2021 to our emergency department. She had a history of epigastric pain and hypertension. She consulted for dyspnea, constipation and abdominal pain that lasted for 24 hours. The patient was suspected to have severe COVID-19 and was admitted to the intensive care unit of the emergency department. The initial workup was a Rapid COVID-19, the COVID-19 PCR and Chest X-ray, which were negative and showed a gastric pocket on the left chest. We suspected a diaphragmatic hernia. The next day, the patient underwent thoracoabdominal computed tomography, which revealed a left diaphragmatic hernia with signs of intestinal necrosis, suggestive of strangulation. The electrocardiogram showed sinus tachycardia with normal left ventricular function on the ultrasound. The patient underwent emergency laparotomy, which revealed intestinal necrosis, and the spleen was accidentally lacerated and the stomach ascended into the left thoracic cavity. The gangrened ileum was resected with loop stoma formation, the spleen was removed, and the hernia orifice was repaired by interrupted stitches. Unfortunately, the patient died on the 4th post-operative day due to Multiple Organ Dysfunction Syndrome. Conclusion: Strangulated Bochdalek hernia is a rare emergency condition with nonspecific signs. It requires a rapid and comprehensive workup to avoid delays in diagnosis. Surgery is the definitive treatment. In elderly individuals, the success of the management is conditioned by the existence of morbidities which may not be fully addressed before surgery, intensive and rapid perioperative resuscitation. The triage process during the pandemic can also contribute to worse prognosis, especially in low-income countries.