Tropical Doctor 2017, Vol. 47(3) 263–266 ! The Author(s) 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475516668964 journals.sagepub.com/home/tdo Left anteromedial strangulated congenital diaphragmatic hernia in an 11-year-old child: a case report Kamal Nain Rattan 1 , Jasbir Singh 2 and Poonam Dalal 3 Keywords Congenital, diaphragmatic hernia, intestinal gangrene Introduction Congenital diaphragmatic hernia (CDH) was first described by Riverius in 1679. 1 It consists of herniation of abdominal contents of a variable extent into the thoracic cavity. Embryological defects in the dia- phragm during intrauterine life are thought to be the underlying cause. The reported incidence is 1:2000 to 1:5000 live births with no gender preference. 2 It usually presents immediately in the newborn period with severe respiratory distress. CDH is more commonly seen on the left side as the right pleuroperitoneal canal closes earlier and the presence of the liver is also thought to block the right side partially. 3 Malrotation of the gut and pulmonary hypoplasia are the most commonly described associated anomalies. 4 CDH may rarely pre- sent late in early childhood and adulthood with atypical symptoms; this often leads to misdiagnosis and delay in corrective measures. The prognosis is, however, excel- lent when CDH presents beyond the neonatal period. 5 Nonetheless, complications such as gastric strangula- tion, gut ischemia with perforation and shock may occur and prove fatal. Case report A previously healthy 11-year-old girl presented as a paediatric emergency with bilious vomiting, abdominal distension and pain with constipation. Vital signs on examination were normal. The abdomen was found to be distended and bowel sounds were increased. No air entry was heard in the left hemi-thorax and heart sounds were audible on right. A chest radiograph showed a large thoracic fluid level on the left side with a marked mediastinal shift (Figure 1). Ultrasound scan demonstrated dilated loops of gut and free fluid in the pelvic cavity and, similarly, the presence of dilated intestine in the left hemi-thorax with a small pleural effusion. Nasogastric aspiration was commenced to decompress the dilated bowel and intravenous fluid rehydration instituted. A full blood count and renal function tests were within normal limits. Contrast computed tomography (CT) of the chest confirmed the diagnosis of CDH and demon- strated underlying lung collapse (Figure 2). Laparotomy was performed through a left sub costal incision. The liver, spleen and gastro-oesophageal junc- tion along with the stomach were present in the abdo- men cavity. Through an anteromedial diaphragmatic defect of approximately 3 cm in size, the ileum had her- niated into the left thoracic cavity. Reduction of the dilated herniated ileum was impossible owing to the small size of diaphragmatic defect, which was thus extended by a lateral incision (Figure 3). Non-viable dilated bowel was then reduced into the abdomen and resected with an iliocolic anastomosis. The underlying collapsed lung was noted. Once the diaphragmatic defect was closed the abdomen could also be closed. No intercostal chest tube was placed. Postoperative recov- ery was uneventful. A repeat chest radiograph showed significant lung expansion after one week (Figure 4). Discussion Congenital diaphragmatic hernia presenting beyond neonatal age is a very rare clinical entity with an 1 Senior Professor and Head, Department of Paediatric Surgery, PGIMS, Rohtak, Haryana, India 2 Senior Resident, Department of Paediatrics, PGIMS, Rohtak, Haryana, India 3 Associate Professor, Department of Paediatrics, PGIMS, Rohtak, Haryana, India Corresponding author: Jasbir Singh, Senior Resident, Department of Paediatrics, PGIMS, Rohtak, Haryana 124001, India. Email: jasbir2001@gmail.com Rattan et al. 263