Forensic Features of Lethal Late-Presenting Diaphragmatic Hernias

Spontaneous Right-Sided Diaphragmatic Hernia: A Rare Cause of Small Bowel Obstruction

Diaphragmatic hernia (DH) is an uncommon cause of small bowel obstruction (SBO), particularly in the absence of trauma. This rarity can pose a diagnostic challenge, leading to significant delays in treatment and increased morbidity. We report a case of a 79-year-old male patient who presented with acute signs of small bowel obstruction. The patient had no reported history of trauma. Computed tomography (CT) of the abdomen revealed a diaphragmatic hernia causing small bowel obstruction. The patient underwent an initial laparoscopy, which was converted to laparotomy, small bowel resection, and subsequent hernia repair. The patient made a good recovery, and two weeks after his initial presentation, he was discharged home. This case highlights the importance of considering diaphragmatic hernia in differential diagnosis for small bowel obstruction, even in the absence of trauma.

Traumatic Diaphragmatic Injuries at Medicolegal Autopsy: A 1-Year Prospective Study

INTRODUCTION

Traumatic diaphragmatic injuries (TDIs) are relatively rare. The forensic literature pertaining to TDIs consists mainly of case studies, suggesting little attention to these injuries during autopsies and research.

MATERIALS AND METHODS

This prospective study was conducted at the Ga-Rankuwa Forensic Pathology Services mortuary over a 1-year period. We included all cases who had a full medicolegal autopsy, as prescribed by the relevant South African legislation (Inquest Act 58 of 1959). All diaphragms were examined by a forensic medical practitioner performing the autopsy.

RESULTS

Nine hundred ninety-nine cases were analyzed; of these, 71 cases with TDIs were identified. The incidence of TDI was, therefore, determined to be 7.11%. A total of 60.56% involved the right hemidiaphragm, 19.72% the left hemidiaphragm, and 19.72% were present bilaterally. A total of 85.92% were present in men and 14.08% in women. Blunt force trauma comprised 33.80%, and penetrative trauma 61.97%. Most were associated with severe injuries. A total of 12.68% had organ herniation through the defects present.

CONCLUSIONS

Our study revealed that TDIs were more common than initially reported. The right side was more often involved in our study than in other studies. Diaphragmatic injuries were observed in 21.46% of all penetrative trauma cases received in a year.

Death by late presenting of diaphragmatic hernia in an infant: case report and review of the literature

Background

Congenital diaphragmatic hernia (CDH) is a congenital malformation of the diaphragm, resulting in the herniation of the abdominal organs into the thoracic cavity. If not properly diagnosed before or at birth, CDH represents a life-threatening pathology in infants and a major cause of death. We present a fatal case of congenital diaphragmatic hernia corresponding to Bochdalek hernia, discovered incidentally during a sudden death’s autopsy of an infant. To achieve a better view of the range of these anomalies, we also conducted a literature review on this subject describing the pathogenesis, manifestations, diagnosis, and autopsy contribution to addressing these CDH.

Case presentation

The case involved a 4-month-old female infant who presented sudden respiratory difficulties after breastfeeding. External examination found marked cyanosis with no evidence of trauma. Upon opening the chest cavity, the stomach, markedly distended, was occupying much of the left pleural cavity. The left lung was compressed and displaced superiorly, and the heart was also compressed and deviated to the right. This mediastinal deviation was due to an ascension of the stomach into the chest cavity through a 2 × 1.5 cm defect in the posterior left hemidiaphragm. Further examination remarked an ecchymotic appearance of the stomach portion entrapped in the hernia defect suggesting recent strangulation of the stomach. The lungs showed atelectasis with signs of pulmonary infection in the histology study.

Conclusions

CDH might be considered uncommon and not always mentioned in the list of sudden death in infant causes. Forensic pathologists should know of this malformation in order to apply the best autopsy techniques and thus allow positive feedback to pediatricians considering the possible legal implications.

Incidental Finding of Right-Sided Idiopathic Spontaneous Acquired Diaphragmatic Hernia

Spontaneous acquired diaphragmatic hernia is a rare finding which occurs in the absence of any trauma or surgery. Here, we present the case of an 83-year-old male who presented to the outpatient department complaining of nausea, vomiting, epigastric pain and sensation of fullness, loss of appetite, and occasional episodes of constipation, with no history of trauma or surgery. Clinical examination revealed no specific cause. A clinical diagnosis of cholelithiasis was initially suspected and confirmed by an ultrasound of the abdomen. However, considering the worsening of symptoms, a computed tomography scan revealed an incidental right-sided spontaneous diaphragmatic hernia. A subsequent laparoscopic surgery for cholecystectomy and the correction of the right-sided defect in the diaphragm was performed. spontaneous acquired diaphragmatic hernia occurring secondary to a defect on the right side of the diaphragm without any history of trauma or surgery is an extraordinary and infrequent radiological finding. Considering the challenging clinical diagnosis of such hernias, clinicians should be vigilant when patients exhibit worsening symptoms of nausea, vomiting, and gastrointestinal obstruction with or without respiratory and cardiac complications. The surgical management of such hernias is effective and secure and usually requires either an abdominal or thoracic approach and a combination of both accesses in some cases.