The clinical picture exhibited by patients bearing a Bochdalek hernia fluctuates between the absence of symptomatology and severe complications. The symptoms that arise may be induced by the abnormally positioned internal organs or the respiratory distress their dislocation causes [11]. 

Symptoms relate to gastrointestinal malfunction include nausea, abdominal pain, constipation and others, whereas pulmonary compromise may be followed by symptomatology such as dyspnoic phenomena, thoracic pain or wheezing sounds. As for the course of the disease, it may display a periodic nature, with remission of symptoms at certain intervals. On the other hand, a large number of patients, almost half of them, present acutely with critical complications, such as organ strangulation [12]. These patients have increased mortality and may even experience sudden death caused by strangulated organs. Another infrequent yet possible complication is a hernia-induced gastric volvulus.

• Pain

  Symptoms are often non-specific and include abdominal pain, dyspnea, chest pain and nausea and vomiting [10]. [bjuinternational.com]

  Symptoms of the Bochdalek hernia include: Abdominal pain Chest pain Difficulty breathing Indigestion Intestinal blockages Due to Joan's discomfort, the specialist discusses potential treatment options for her Bochdalek hernia. [study.com]

  If symptomatic, the most common presentation is thoracic and abdominal pain, respiratory stress, and bowel obstruction. Differential diagnosis includes diaphragmatic rupture and Morgagni hernia. [eurorad.org]

  Recurrent abdominal pain, postprandial fullness and vomiting are the most common abdominal symptoms in adults [ 2 ]. Our patient was experiencing the typical symptoms of abdominal pain and pleural effusion. [jmedicalcasereports.biomedcentral.com]

• Asymptomatic

  CASE PRESENTATION: An asymptomatic 76-year-old woman was diagnosed with advanced gastric cancer during follow-up after radiotherapy for uterine cervical cancer. [ncbi.nlm.nih.gov]

  A conservative approach can be proposed in asymptomatic cases. In this report, the case of a 35-year-old man presenting with 1-week of acute abdominal pain is presented. [mjdrdypu.org]

  Whilst asymptomatic BH tend to occur equally on the right and left hand sides of the diaphragm [3,4], symptomatic BH tend to occur on the left with a ratio of 9:1 [1,2]. [bjuinternational.com]

  It is a birth defect that has remained asymptomatic for 56 years. The diagnosis is made at the stage of acute gastric volvulus on diaphragmatic hernia, which is life threatening. The patient was prepared for laparoscopic diaphragmatic repair. [journals.lww.com]

• Fever

  A 20 year old female presented with complaints of dry cough since 15 days and intermittent fever of 4 days duration. [lungindia.com]

  Sudharshan was admitted to the KGMCH on February 2 with infection in lower respiratory tract, fever, difficulty in breathing, abdominal pain and vomiting. [thehindu.com]

  No history of recent fever, traumatic injuries or vomits. Imaging Findings Abdominal radiography one month earlier on the onset of the symptoms was normal. (Fig. 1) Abdominal ultrasound revealed a significant volume of ascites. [eurorad.org]

  In view of persistent fever, contrast enhanced CT scan of chest and abdomen was done with positive oral contrast. While administering contrast orally, the resident observed contrast coming through the intercostal tube drain. [tropicalgastro.com]

  Noh, Kim, Seo, Wie, and Chang: Intrathoracic kidney with left-sided Bochdalek hernia in a woman with bacteremic acute pyelonephritis due to Escherichia coli A 56-year-old Korean female attended the emergency department complaining of fever, abdominal [kjim.org]

• Gangrene

  An exploratory laparotomy was performed that revealed an intestinal malrotation associated with a right gangrenous and perforated Bochdalek hernia. [ncbi.nlm.nih.gov]

  Codes K44 Diaphragmatic hernia K44.0 Diaphragmatic hernia with obstruction, without gangrene K44.1 Diaphragmatic hernia with gangrene K44.9 Diaphragmatic hernia without obstruction or gangrene [icd10data.com]

  In such instances it is usually necessary to convert to an open operation and remove a portion of the gangrenous organ and fix the hernia. [laparoscopyindia.com]

• Weight Loss

  Case Report A 64 year old male presented with a 6 month history of cough, shortness of breath and weight loss. The patient had an insignificant past medical and family history. [jpma.org.pk]

  loss in a 6 mo-period. [wjgnet.com]

  The patient reported no history of abdominal or thoracic trauma or recent fever, weight loss, or diarrhea. On physical examination, the patient's abdomen was distended, and palpation elicited diffuse pain. [mdmag.com]

• Abdominal Pain

  If symptomatic, the most common presentation is thoracic and abdominal pain, respiratory stress, and bowel obstruction. Differential diagnosis includes diaphragmatic rupture and Morgagni hernia. [eurorad.org]

  This report describes a young man with acute abdominal pain and incarceration of the colon. Clinicians should keep this rare diagnosis in mind when evaluating an adult patient with acute abdominal pain for early diagnosis and improved outcome. [ncbi.nlm.nih.gov]

  Recurrent abdominal pain, postprandial fullness and vomiting are the most common abdominal symptoms in adults [ 2 ]. Our patient was experiencing the typical symptoms of abdominal pain and pleural effusion. [jmedicalcasereports.biomedcentral.com]

  Our patient presented with abdominal pain. Symptoms may be intermittent or acute depending on the extent of herniation of abdominal viscera into the thorax. [jmedicalcasereports.org]

• Constipation

  Case Report: A 58 year old female presented with abdominal pain and constipation. On examination bowel sounds heard in left sided chest. X-ray chest suggestive of air-fluid level in left lung field and shift of mediastinum structure to right. [scopemed.org]

  The patient presented with chronic intermittent constipation, nausea, and emesis. A CT scan revealed the hernial defect. Comments Nice work, Igor. [ctsnet.org]

  Precipitating factors are sometimes identified and include any mechanism that increases intra-abdominal pressure, however, the patient in our study did not have any history of chronic cough or constipation. [bjuinternational.com]

  Thus, BH may occur as an asymptomatic chest mass, atypical chest, upper abdominal pain or discomfort, breathlessness, cough, dysphagia and gastrointestinal obstructive symptoms such as vomiting and constipation due to herniation of the stomach or bowel [pneumon.org]

• Epigastric Pain

  A 38-year-old woman presented with epigastric pain and a persistent cough of 2 months' duration. A chest radiograph showed bowel loops in the left side of the chest. [ncbi.nlm.nih.gov]

  Here, we report a case of a 56-year-old woman diagnosed with epigastric pain, cough, vomiting since 2 weeks and shortness of breath. [journals.lww.com]

• Tenderness in the Epigastric Region

  A physical examination revealed tenderness in the epigastric region with costovertebral angle tenderness and decreased breath sounds in the left lower lung. Initial urine and blood cultures revealed Escherichia coli. [kjim.org]

• Choking

  This can happen for a variety of reasons, such as they are too weak or tired from the surgery, or they are not able to safely take foods by mouth without coughing or choking. [pediatric.surgery.ucsf.edu]

• Tachycardia

  We present a case of a 42-year-old female patient who presented with a 3-month history of left-upper-quadrant abdominal pain, nausea, tachycardia, and early postprandial vomit. [ncbi.nlm.nih.gov]

  On physical examination, she was normotensive, febrile (1010F) and had tachycardia. There was fullness on the right side of the chest and the trachea was shifted to the right side. [tropicalgastro.com]

• Back Pain

  We present here a rare case of Bochdalek hernia in an elderly patient who suffered from sudden back pain and had the hernia repaired with laparotomy. [ncbi.nlm.nih.gov]

  Abdominal or back pain, changes in bowel habits, vomiting, nausea, or abdominal distension are the abdominal symptoms of Bochdalek hernia. As in the present case, the physical examination of Bochdalek hernia in adults is typically misleading. [tgkdc.dergisi.org]

  The patient was discharged with a presumptive diagnosis of chronic back pain. [bjuinternational.com]

  They can be not only gastrointestinal symptons, such as nausea, postprandial vomiting, abdominal pain, back pain, post-prandial bloating; but also respiratory complaints, such as dyspnea, chest pain, shoulder referred pain 5, 8. [scielo.br]

  If a hernia suddenly grows larger, becomes tense, and will not go back into place, and there is pain and nausea, it is strangulated. [medical-dictionary.thefreedictionary.com]

• Contusion

  They can be classified as congenital (such as those of Morgagni-Larrey, Bochdalek), acquired (such as different types of hiatal hernia) or post-traumatic (due to a closed contusion or a lacerating lesion) [5]. [medical-clinical-reviews.imedpub.com]

• Confusion

  Many a times intrathoracic kidney is confused with a thoracic mass and the patient undergoes a battery of unnecessary investigations, surgical interventions and image guided biopsies for the same, hence to avoid this we are reporting this case. [lungindia.com]

  So confusing!! I think the appropriate code would be 39561. Last edited: Jun 16, 2020 [aapc.com]

  Plain film can give an idea of the hernia with the colon gas seen over the diaphragma 8, but plain film has low sensitivity and it can lead to misdiagnosis and confusion with other thoracal pathologies like left middle lobe collapse, air space consolidation [causapedia.com]

  A BH may be confused with other thoracic pathologies, such as lingular collapse, consolidation, a pericardial fat pad, sequestration of the lung, mediastinal lipoma, or a mediastinal mass due to the low sensitivity of plain chest X-rays.[13,20] On the [tgkdc.dergisi.org]

  Due to the low sensitivity of plain film chest radiography, Bochdalek hernias may be confused for other thoracic pathology including left middle lobe collapse, air space consolidation, pericardial fat pad, sequestration of the lung, mediastinal lipoma [ncbi.nlm.nih.gov]

• Irritability

  A physical examination revealed muscular rigidity in the left upper quadrant of the patient's abdomen without rebound tenderness or signs of peritoneal irritation. The rectal examination revealed no masses or bleeding. [scielo.br]

  You will learn to recognize when your child has increased effort with breathing, a color change, retractions or irritability. All of these changes suggest that your child may be experiencing a breathing problem. [pediatric.surgery.ucsf.edu]

  To help prevent symptoms, avoid common irritants like smoke, dust and some animals. Our SPF clinic watches for early signs of asthma in children with CDH to be sure it is treated correctly. [seattlechildrens.org]

It is common for a patient with a Bochdalek hernia to experience no symptoms, in which case the herniation will probably be diagnosed incidentally during a test conducted for other reasons. If the hernia does produce symptoms, those are generally non-specific indications of gastrointestinal or pulmonary dysfunction. A plain radiograph will most of the times illustrate a mass consisting of soft tissue or an intestinal loop filled with air that lies above the diaphragm; however, since these findings can be misinterpreted as various other pathologies related to the thorax, a computerized tomography scan is mandatory for a definitive diagnosis. Barium or gastrographin meal and enema can be also applied and are able to safely diagnose a diaphragmatic hernia of any size. A definitive diagnosis and accurate detection of the location of the hernia are important, because of the need to plan an appropriate surgical approach in order to treat the visceral herniation.

• Atelectasis

  A left pleural effusion was also observed with basal laminar atelectasis, scarce free fluid in the left and right slider, being more accentuated towards the pelvic cavity. [medical-clinical-reviews.imedpub.com]

  When symptoms do occur, they are relatively nonspecific and include chest or abdominal pain. 5 Bochdalek hernia can be misdiagnosed as pleural effusion, pneumonia, pneumothorax, lung cysts, mediastinal tumour and atelectasis. 1 Footnotes Previously published [cmaj.ca]

  The second patient, who had recently recovered from aspiration pneumonia, required supplemental oxygen and had post-operative atelectasis on chest x-ray, but he was discharged form the hospital on room air after 5 days. [sages.org]

  Differential diagnosis on admission included a possibility of pulmonary embolism, COPD exacerbation, pneumonia, and atelectasis, but those were ruled out appropriately during the diagnostic workup. [rc.rcjournal.com]

• Left Pleural Effusion

  […] a rare case of congenital diaphragmatic Bochdalek hernia in an adult stimulating left pleural effusion. [degruyter.com]

  The authors present a rare case of congenital diaphragmatic Bochdalek hernia in an adult stimulating left pleural effusion. The diagnosis of left pleural effusion was made on the basis of conventional chest X-ray and ultrasonography. [ncbi.nlm.nih.gov]

  Chest X-ray on admission showed a large amount of left pleural effusion. Thoracentesis revealed hemorrhagic pleural effusion. An upper gastrointestinal series showed interruption of the upper gastric body, but the anal side was not visualized. [karger.com]

  The case of an eleven-months-old girl is reported: she entered the intensive care unit for fever, vomiting and left pleural effusion. Abdominal echography, CT scan and colonic opacification led to the diagnosis of a colonic Bochdalek hernia. [scienceopen.com]

  A left pleural effusion was also observed with basal laminar atelectasis, scarce free fluid in the left and right slider, being more accentuated towards the pelvic cavity. [medical-clinical-reviews.imedpub.com]

A Bochdalek hernia is treated surgically, aiming at the reduction of the abdominal contents and the correction of the initial defect that lead to the development of the hernia. Approaches vary depending on the size and location. Herniation that takes place on the right side of the diaphragm is treated with a thoracic approach or a combination of a thoracic and abdominal approach. On the other hand, hernias of the left section of the diaphragm are more challenging in terms of surgical intervention: a thoracic approach is implemented by some surgeons, because it allows for a better elimination of adhesions between the chest organs and the pouch of the hernia. Others, on the other hand, conduct a laparoscopic surgical procedure to better handle a malrotation incident. At any case, a mesh is used to compensate for the opening on the diaphragm and pain must be appropriately managed during the period after surgery, alongside respiratory monitoring.

Mortality rates associated with congenital diaphragmatic hernias have been exhibiting a steady decline, thanks to the advent of new and progressive treatment techniques, as well as diagnostic modalities that help to diagnose the defect in patients without symptoms [10]. Significant morbidity does not arise as a result of the hernia itself, but due to the underlying conditions that it is associated with, such as neurodevelopmental disorders.

Bochdalek and Morgagni hernias are the two types of congenital diaphragmatic hernias. Almost 97% of congenital diaphragmatic hernias are of the Bochdalek type [5]. They are located posteriorly and are a result of a defective diaphragm continuity; defects are caused by an underdeveloped pleuroperitoneal membrane or a failure of the diaphragm's musculature to migrate.  

The degree of herniation and subsequent symptomatology plays a role in the number of Bochdalek hernias diagnosed amongst the general population. Such hernias are rarely diagnosed in the adult life; however, pediatric patients diagnosed with a Bochdalek hernia until the age of 1 year old run a greater risk of death due to respiratory compromise. According to necropsical data [6] [7], the Bochdalek hernia has an incidence amounting from 1/2000 to 1/7000; CT- derived data, on the other hand, illustrate a potential incidence that can reach 6% [8]. 

From a pathophysiological point of view, a Bochdalek hernia develops when an organ that is normally confined within the abdomen protrudes through the diaphragm. The diaphragm acts as a natural barrier that separates the thoracic from the abdominal cavity and consists of muscle and fibrous tissue. During the course of fetal development, the septum transversum, the cervical myotomes, the dorsal mesentery and the pleuroperitoneal membranes are the components from which the diaphragm is built. 

The diaphragmatic anatomical structure is expected to be fully matured by the 8th week of pregnancy. Congenital defects, such as impaired pleuroperitoneal membrane closure or migration of muscle cells, result in a diaphragmatic structure that lacks the complete set of characteristics needed to prevent the sliding of the organs from one cavity to another. Hence, the diaphragm is vulnerable and allows the protrusion of intra-abdominal organs through its structures. 

As far as general diaphragmatic anatomy is concerned, the arterial supply to the diaphragm is conducted via the phrenic arteries (left and right), intercostal arteries and branches of the internal thoracic arteries. It is innervated by the phrenic nerve: originating from the 4th cervical ramus, this nerve follows a lengthy route before it reaches the diaphragm and therefore, any obstacle or damage sustained at any point of the route leads to problems associated with the diaphragm itself [9].

A Bochdalek hernia cannot be prevented, as it is caused by developmental defects during the formation of body structures in an embryo.

A Bochdalek hernia is one of the two types of diaphragmatic hernia. It was named after A. Bochdalek, the physician who first described it in the 19th century and is a congenital abnormality [1].

The segregation between the abdominal cavity and the thoracic space is achieved by the diaphragm, which keeps the organs in their appropriate place. Occasionally, the posterior diaphragmatic attachment is impaired, because the pleuroperitoneal membrane fails to close during fetal development. This particular location is responsible for herniation phenomena, since the structure fails to restrain organs and keep them in place. A Bochdalek hernia is formed when organs located in the abdomen and especially the intestines and stomach, protrude through the posterior defective region of the diaphragm. This type of hernia occurs primarily on the left posterior diaphragmatic side at a rate of 85%.

A significant protrusion of an abdominal organ into the thoracic cavity usually causes symptomatology related to pulmonary function, as the lung will also be defective due to lack of space [2]. This constitutes a severe complication, as an infant may well succumb to respiratory arrest, if the hernia remains undiagnosed and the lung is extremely compromised.

Bochdalek hernias are mostly diagnosed during infancy; in adults they are quite rare, with only a hundred known cases of adult Bochdalek hernias worldwide [3]. A Bochdalek hernia constitutes 0.2 to 6% of all hernias of the diaphragm [4]. During the past years, with the advent of computerized tomography imaging (CT), the number of Bochdalek hernias diagnosed has exhibited an increase. The other type of congenital diaphragmatic hernia is the Morgagni hernia, where an intra-abdominal organ protrudes into the thoracic cavity through the foramen of Morgagni. This type of hernia is located anteriorly and is rarer than a Bochdalek hernia.

The optimal way of treating a Bochdalek hernia is surgery; a thoracic approach, an abdominal one or a combination of the two are used to achieve a permanent repairment of the diaphragmatic opening via a mesh and relocate the protruding organ into its normal cavity.

A Bochdalek hernia is a congenital anomaly, in which abdominal organs protrude through the diaphragm into the thoracic cavity. The diaphragm is a structure that separates the chest are from the abdomen and prevents the translocation of internal organs, while at the same time providing openings, so that organs (such as the esophagus) can pass through. 

During the development of the fetus in the womb, various abnormalities of the diaphragm may render it unstable and weak at some locations. Pressure from internal organs, combined with the congenital defects of the diaphragm lead to the formation of openings, through which organs found in the abdomen, most commonly the stomach and intestine, actually find their way up to the chest. Depending on the size and location of the hernia, lungs may be subject to distress, leading to pulmonary dysfunction.

Bochdalek hernias are congenital and are mostly diagnosed during the first year of a child's life. They are only rarely detected during the adult life. A patient may experience no symptoms caused by the hernia, or alternatively, they may report symptoms attributed to the gastrointestinal system or the pulmonary system. While an internal organ protrudes through a narrow opening, its function is distorted: it may be strangulated and the flow of its contents hindered. That is why a Bochdalek hernia may cause bowel obstruction, nausea and abdominal pain. If an abdominal organ is severely strangulated, the condition is treated as a medical emergency. On the other hand, the lungs lack the adequate space they need to function in case an organ ascends into the thoracic cavity and related symptomatology includes chest pain and dyspnea amongst others.

A Bochdalek hernia is diagnosed non-invasively, with the use of x-ray scans, a CT scan or a barium enema. Imaging modalities help to differentiate such a hernia from other abnormalities of the chest. Its treatment is surgical; the location may be accessed through the abdomen or thorax, either in an open fashion or laparoscopically.

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