Case Presentation
A six-year-old female child diagnosed with CDH at one month of her life was brought to the outpatient department of our hospital to evaluate her congenital condition.
One month after birth, the child developed difficulty breathing. This was not associated with grunting, intercostal or subcostal retraction, fever, inability to feed, vomiting, drowsiness, or convulsions. For this complaint, she was taken to a local hospital for further evaluation. A plain radiograph of the chest revealed air-filled loops of intestines in the left lung field. A diagnosis of left-sided congenital diaphragmatic hernia was established, and the patient was managed conservatively for respiratory distress. Since then, the patient remained asymptomatic and was eventually lost to follow up.
On admission to our hospital, the child was completely asymptomatic. Clinically, her general condition was fair, and she was playful. Her respiratory rate was 34/min, pulse was 98/min, and the temperature was 38.40 C. There was no pallor, icterus, cyanosis, edema, palpable lymph nodes, or dehydration. The abdomen was scaphoid-appearing, and bowel sounds were heard over the left lung field. The point of maximum cardiac impulse was 3 cm below and medial to the nipple.
Blood investigation showed: hemoglobin 12.2 gm/dl, white blood cells 5400/mm3 (lymphocytes 67%, neutrophils 30%), and platelets 210000/mm3. Her renal function tests showed: urea 3.4 mmol/l and creatinine 26.52 µmol/L. Blood sugar level, liver function tests, serology, and urine routine and microscopic examination were normal. Barium follow-through study showed the presence of stomach and small bowel loops in the left hemithorax (Figure 1). Contrast-Enhanced Computed Tomography (CECT) scan of the chest and abdomen revealed a breach in the posterolateral aspect of left hemidiaphragm measuring approximately 5x3.2 cm. Intraabdominal contents (small and large bowel, spleen, stomach, mesentery, and mesenteric vessels) were also noted in the left hemithorax leading to a decrease in the abdominal volume and a mediastinal shift to the right. All the imaging findings were suggestive of diaphragmatic hernia, Bochdalek type. The pre-operative echocardiographic finding showed normal pulmonary artery pressure.
The patient was planned for laparotomy. The operative finding was a 6x4 cm defect in the left dome of the diaphragm and herniation of intraabdominal contents (stomach spleen, part of jejunum, and transverse colon) without a sac. The intrathoracic contents were reduced back into the abdomen, and the defect was sutured (Figure 2). An intercostal chest tube (size 14 French) was also placed in situ intraoperatively.
She was admitted to the surgical intensive care unit (SICU) and kept under mechanical ventilation (volume control synchronized intermittent mandatory ventilation mode) for one postoperative day and empiric antibiotics (cefotaxime and metronidazole). She had one spike of fever on the third postoperative day following which her antibiotics were changed to meropenem. Chest tube drainage showed a maximum daily output of 350- 400 ml (approximately 26ml/kg/day) of straw-colored fluid for the first seven postoperative days. The daily postoperative chest drain output is shown in a line graph (Figure 3). On the eighth postoperative day, the fluid turned milky white. The pleural fluid analysis showed: lymphocytic predominance (90%), triglycerides 210 mg/dl, and cholesterol 23 mg/dl. With a diagnosis of postoperative chylous pleural effusion, the patient was kept nil per os for three more days. She was treated with intravenous 20% albumin infusion and antibiotics (meropenem and metronidazole). The volume of the chest tube drainage subsequently decreased to 250 ml/day. From the 11thpostoperative day, she was kept on low fat and high protein diet. By the 21st postoperative day, the fluid output decreased to 75ml/day. On the 27th postoperative day, the chylothorax output decreased to 20 ml/day, and hence the tube was clamped for two days. On the 29th postoperative day, the chest tube was finally removed. By then, her appetite returned to normal, the wound looked healthy, and she was eventually discharged on the 31st postoperative day.