The way to a man's heart is through his stomach? A unique case report of transient constrictive pericarditis secondary to infarction of herniated omentum following bariatric surgery

Background

Intrapericardial diaphragmatic hernias are a rare form of diaphragmatic hernia. The presentation is usually acute due to trauma or from iatrogenic causes. In some instances however, these patients can present years later. We describe an unusual case of transient constrictive pericarditis associated with herniation of omentum through a diaphgragmatic hernia extending into the pericardial space, which infarcted following recent bariatric surgery. A multi-disciplinary approach was required with surgical correction of the diaphragmatic defect and removal of omentum from the pericardial space.

Case summary

A 38-year-old gentleman with a history of a remote abdominal stab wound and recent laparoscopic gastric sleeve procedure presented with sharp central chest pain radiating to the shoulder. Chest imaging [echocardiography, computed tomography (CT), and cardiac magnetic resonance imaging (MRI)] revealed the presence of an intrapericardial diaphragmatic hernia and herniation of devascularized omentum into the pericardial space. Surgery was undertaken to remove the pericardial omentum. Echocardiography and cardiac MRI revealed changes of pericardial constriction which resolved with anti-inflammatories.

Discussion

A multi-disciplinary approach was required in this case with surgical correction of the diaphragmatic defect and removal of omentum from the pericardial space. Multi-modal imaging proved essential in the diagnosis of this rare condition, aiding in timely diagnosis, ongoing management decisions, and for assessing therapeutic response.

Case report of traumatic intrapericardial diaphragmatic hernia: Laparoscopic composite mesh repair and literature review

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Post-traumatic rupture of the diaphragm with herniation of abdominal viscera into the pericardium is a rare injury.

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Delayed diagnosis of Intrapericardial diaphragmatic hernia does not preclude laparoscopic repair.

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Repair of large defect with composite mesh reduces the risk of adhesions, infection and erosion of nearby viscera.

Introduction

Traumatic rupture of the diaphragm with herniation of abdominal viscera into the pericardium is a rare injury. We present a case of intrapericardial diaphragmatic hernia after one year of thoracoabdominal trauma. This case is the 106th in the literature and only the fifth treated by the laparoscopic approach including this case. After case presentation, we will discuss post-traumatic intrapericardial diaphragmatic hernias by reviewing the literature.

Case presentation

A 48-year-old male presented to our outpatient clinic with a history of thoracoabdominal trauma due to a motor vehicle accident one year ago. The patient complained from abdominal pain and constipation over the last year. After a thorough history and physical examination, thoracoabdominal computed tomography (CT) was performed. The CT scan revealed herniation of the transverse colon and omentum through a large anterior diaphragmatic defect into the pericardial sac. Laparoscopic composite mesh repair was done. The patient had an uneventful postoperative course and was discharged home on the second postoperative day. The patient was asymptomatic at regular follow-up six months postoperatively.

Conclusion

Late presentation of intrapericardial diaphragmatic hernia is rare. Chest computed tomography is the most useful diagnostic tool. Delayed diagnosis of Intrapericardial diaphragmatic hernia does not preclude laparoscopic repair by primary closure or with mesh according to the size of the defect.

Asymptomatic adult intrapericardial diaphragmatic hernia detected on cardiac SPECT CT

An 83-year-old man underwent exercise stress test with single photon emission computed tomography (SPECT) myocardial perfusion imaging for new electrocardiogram (EKG) changes. The stress EKG did not show any significant changes. Myocardial perfusion imaging with SPECT demonstrated an inferior wall defect and extracardiac uptake of nuclear tracer. Simultaneous cardiac computed tomography performed for attenuation correction showed presence of intrapericardial hepatic tissue in an anterior diaphragmatic hernia. The herniated tissue was noted to influence the perfusion image and cause the defect. To date, this is a unique finding based on review of literature.

Morgagni hernia presenting with massive pericardial effusion and ascites: prenatal management by thoraco-amniotic shunting and fetal endoscopic tracheal occlusion (FETO) and review of the literature

BACKGROUND

Morgagni hernia presents a rare type of congenital diaphragmatic hernia (CDH, about 2-5 %) (Herman, J Perinatol 21:343-344, 2001), which is characterized by an anterior mainly right-sided defect of the diaphragm. Infrequently, this is combined with a herniation of the liver into the pericardial cavity (Aké, Prenat Diagn 11:719-724, 1991; Stevens, Pediatr Radiol 26:791-793, 1996). This may cause massive pericardial effusion and subsequently lung hypoplasia (Pober et al., Congenital diaphragmatic hernia overview, University of Washington, Seattle, 2015; Ikeda, J Perinat Med 30:336-340, 2002; Hara, J Obstet Gynaecol Res 33:561-565, 2007). So far only few cases have been reported in fetal life.

CASE

We report a case of Morgagni hernia with pericardiodiaphragmatic aplasia, complicated by two-compartment effusions (massive pericardial effusion and mild ascites), diagnosed in the second trimester. The case was successfully managed in utero with thoraco-amniotic shunting and late tracheal occlusion, followed by corrective surgery after birth.

DISCUSSION

A review of the literature was performed, identifying 13 cases of prenatally diagnosed Morgagni hernia. The diagnosis was established by the sonographic findings of pericardial effusion und intrathoracic herniation of the liver. In only two cases a prenatal intervention was carried out. All neonates were operated postnatally with excellent final outcome.

A Rare Variant of Diaphragmatic Hernia through the Central Tendon: A Case Report

Diaphragmatic hernia through the central tendon is a very rare entity. We report on a case that developed to acute intestinal obstruction, secondary to herniation of the small intestine through a small defect in the central tendon of the diaphragm. The patient never had any trauma to his chest or abdomen and had no history suggestive of congenital nature of the diaphragmatic hernia. However, he had coronary artery bypass grafting with saphenous vein used as a graft, done almost 17 years back; hence, we suspect it to be an iatrogenic hernia. A laparoscopic herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Iatrogenic diaphragmatic hernias are a very rare entity. We are reporting on a central tendon hernial defect in the diaphragm after coronary artery bypass with saphenous vein as a graft material. There are reported cases with post coronary artery bypass graft diaphragmatic hernia in which the right gastroepiploic artery was taken as the graft material. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. CT scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients.