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.