Intestinal Obstruction Due to Bochdaleck´s Hernia in an Adult

rare a 36-year-old previously epigastric of a sudden onset that to the along with and No fever or other symptoms were observed. Physical examination, laboratory data, and no A chest X-ray an in the lower hemythorax with a liquid level, whereas a flat abdominal X-ray examination a small bowel obstruction. Surgery was performed under general anesthesia with single lung ventilation and a laparoscopic approach. Parts of and the cavity through the posterior and lateral defect was 8 cm in No hernia was identified.


Sir,
Bochdalek's hernia is a common congenital anomaly in neonatal and postnatal patients, while being extremely rare in adults. We have examined a 36-year-old previously healthy man who presented with epigastric pain of a sudden onset that radiated to the presternal area along with nausea and vomiting. No fever or other symptoms were observed. Physical examination, laboratory data, and ECG revealed no abnormalities. A chest X-ray revealed an air bubble in the lower left hemythorax with a liquid level, whereas a flat abdominal X-ray examination showed a small bowel obstruction. Surgery was performed under general anesthesia with single lung ventilation and a laparoscopic approach. Parts of the stomach, small intestine, colon, greater omentum, and spleen were herniated into the left thoracic cavity through the posterior and lateral defect that was 8 cm in diameter. No hernia sac was identified. Herniated viscera were pulled back into the peritoneal cavity, and the defect was closed with interrupted sutures. The lung was found to expand normally in the postoperative period. The patient remained asymptomatic 24 months later.
In a recent study, [1] Bochdalek's hernia was diagnosed in 22 patients (17 women, five men), which represents an incidence of 0.17% based on 13 138 abdominal CT reports. The mean age of the patients was 66.6 years; none of the patients was symptomatic. In these patients, 68% of the hernias were located on the right side, 18% on the left, and 14% were bilateral. Of all hernias, 73% contained only fat or omentum, whereas 27% had solid or enteric organs including the spleen or the small or large intestine. Gale [2] showed a 2:1 frequency for right-sided cases, and a bilateral instance of 0.9%; strangulation sometimes occurs. Putative causes for late-presenting hernias include congenital herniation, blunt or penetrating trauma, physical exertion (including sexual intercourse), pregnancy, labor and delivery, sneezing or coughing, and even the ingestion of a large meal.
Diagnosis is ascertained by a combination of chest X-rays, computed tomography (CT), magnetic resonance imaging (MRI), as well as upper gastrointestinal and bowel doublecontrast study. Past normal chest X-rays do not exclude the presence of Bochdalek's hernia.
For right-sided Bochdalek hernias, a transthoracic or thoracoabdominal approach is preferable. For left-sided hernias, some advocate a transthoracic approach, while others suggest a transperitoneal one. A transthoracic approach enables direct observation of the herniated viscera. A transperitoneal approach also allows the surgeon to confirm the position of the viscera after "pull back" and repair any malrotation, if present.
Minimally invasive procedures-both by thoracic or abdominal approaches-have been demonstrated to be   A 66-year-old hypertensive and diabetic woman was referred to us for the evaluation of severe iron deficiency anemia. Clinically she was obese, pale, with stable vital signs, and physical examination revealed no abnormalities. Laboratory data were unremarkable except for a hemoglobin level of 62 g/L; upper endoscopy was normal.
Colonoscopy revealed a 3-cm sessile, polypoid lesion in the cecum, and biopsy was performed [ Figure 1]. A CT scan of the abdomen was normal except for small pericecal lymph nodes. Histology of the polypoidal lesion showed features of an inflammatory fibroid polyp. The patient underwent a second colonoscopy and the polyp was removed using the snare-and-cautery technique without any complications, in small pieces. But at the end the whole polyp was removed leaving only its base.
Microscopically, the lesion was a polypoidal mass of fibromuscular and inflammatory tissue covered by colonic mucosa. The latter was continuous with the underlying tissue and had focal ulceration and granulation tissue formation. The lesion was composed of a highly vascular tissue with bland fibroblast-like cells and an inflammatory infiltrate of lymphocytes, eosinophils, and plasma cells. In some areas, the inflammation was dense with the formation of reactive lymphoid follicles [ Figure 1].
Colonic IFP is rare and there have only been a total of 44 cases, including our case, reported in the literature. [1][2][3] Out of 26 cases of colonic IFP reported by Sakamoto et al., 17 have been treated surgically. Different techniques have been described for the endoscopic removal of the polyp including the one using the clip-and-cut technique. [4] In our case, a large polypoid lesion was found in the cecum during colonoscopy done as a part of the diagnostic workup for iron deficiency anemia. IFPs originate primarily in the mucosa and submucosa, but they can, in rare instances, extend to the muscular layer. In this patient, the IFP was predominantly in the mucosa without any extension to the muscular layer, and hence, we decided to remove this by colonoscopy and the snare polypectomy technique. Followup colonoscopies done three months and a year later showed no residual lesions or recurrence.
As the IFP is a benign polyp and its recurrence is very rare, we believe that its endoscopic removal is an appropriate treatment modality. With wide use of colonoscopy, more such cases of IFP will probably be identified, and awareness of such condition among physicians will help to avoid surgery and resection.