ORIGINAL ARTICLE Essam A. Elhalaby Æ Magda H. Abo Sikeena Delayed presentation of congenital diaphragmatic hernia Accepted: 21 June 2001 / Published online: 31 July 2002 Ó Springer-Verlag 2002 Abstract The late-presenting congenital diaphragmatic hernia (CDH) represents a considerable diagnostic challenge. This study was undertaken to define various patterns of delayed presentation and to analyze pitfalls in the diagnosis and treatment of these patients. Thirty- three children with CDH were treated between 1993 and 2000; 15 of these (45.5%) who were diagnosed after the age of 2 months–14 years, median of 2.5 years are re- ported. Thirteen had a Bochdalek hernia and 2 had a Morgagni hernia. The diaphragmatic defect was right- sided in 6 cases and left-sided in 9. Five patients pre- sented acutely, 3 with respiratory distress and 2 with gastrointestinal (GI) obstruction. The remaining 10 presented with chronic respiratory or GI complaints. Inappropriate insertion of a chest drain occurred in 3 patients misdiagnosed as having pleural effusion (2) and a pneumothorax (1). Two patients had previous chest radiographs reported normal. Plain radiographs were sufficient to make a definitive diagnosis in only 6 pa- tients; GI contrast studies were necessary in the other 9. All patients were treated through an abdominal ap- proach with primary closure of the diaphragmatic defect without a patch. A distinct hernia sac was present in 6 cases, and associated malrotation in 6. All except 1 pa- tient survived the operation with rapid improvement of their GI and respiratory symptoms. We conclude that: (1) late-presenting CDH should be included in the dif- ferential diagnosis of any child with persistent GI or respiratory problems associated with an abnormal chest X-ray film; (2) nasogastric tube placement must be considered as an early diagnostic or therapeutic inter- vention when the diagnosis is suspected; and (3) GI contrast studies should be a part of the diagnostic work- up of these patients. Keywords Congenital diaphragmatic hernia Æ Pneumothorax Æ Pleural effusion Æ Intestinal obstruction Introduction Considerable attention has been directed in the last 2 decades toward the delayed presentation of Congenital diaphragmatic hernias (CDH) [1–6]. The presentation beyond the neonatal period is extremely varied, and may be associated with misleading clinical and radiologic assessments [5]. Misdiagnosis is a distinct possibility, with the risk of serious morbidity and mortality [1–10]. This study was undertaken to review the various patterns of delayed presentation of CDH and to high- light pitfalls in the diagnosis and treatment of these patients. Patients and methods Thirty-three children with CDH were treated in the departments of pediatric surgery and pediatrics, Tanta University Hospital, from 1993 to 2000. The hospital is an academic referral center located in a rural area in the middle of the Nile delta and serving more than 1 million population. Fifteen (45.5%) of these patients who were older than 2 months at the time of diagnosis form the basis of this study. Patients with posttraumatic and hiatus hernias and even- tration of the diaphragm were excluded. Each child was evaluated as to age, sex, side of herniation, presenting symptoms, history and physical, and roentgenographic findings. At the time of operation, special attention was given to the size and contents of the hernia and the presence of a sac and associated anomalies, particularly malrotation of the midgut and pulmonary hypoplasia. The post- operative records were evaluated for morbidity and mortality. Pediatr Surg Int (2002) 18: 480–485 DOI 10.1007/s00383-002-0743-1 Presented at the IV International Congress of the Egyptian Pedi- atric Surgical Association, Alexandria, 4–6 October 2000. E.A. Elhalaby (&) Department of Pediatric Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt E-mail: eelhalaby@hotmail.com Tel.: +20 40 333 5695, 20 1233 15309 Fax: +20 40 333 5545 M.H. Abo Sikeena Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta, Egypt E.A. Elhalaby Borg Elmhata, Midan Elmhata, Tanta, 31111, Egypt