A Paraesophageal Hernia with Gastric Volvulus in a 16-month-old Boy

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Journal of Investigative Medicine





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Case report A 16-month-old previously healthy male presented to the emergency department (ED) with a 1 day history of non-bloody, non-bilious emesis and progressive feeding intolerance to both solids and liquids without the presence of diarrhoea. Initially, he was diagnosed with a viral syndrome and discharged home. Several hours later, the patient developed projectile emesis and returned to the ED. An abdominal radiograph showed findings suspicious for a diaphragmatic hernia. CT scan revealed gastric outlet obstruction from a portion of stomach located intrathoracically through a left diaphragmatic hernia. He was taken emergently to the operating room where he was discovered to have a left paraesophageal congenital diaphragmatic hernia with gastric volvulus. The patient underwent a laparoscopic reduction with primary closure and Nissen fundoplication. He experienced complete resolution of symptoms and tolerated a soft mechanical diet while receiving care in the paediatric intensive care unit. The patient was discharged home on post-operative day four and was found to be clinically improved at his first outpatient follow-up visit with no further emesis or feeding intolerance. Most cases of congenital diaphragmatic hernias (CDH) are diagnosed in the antenatal or neonatal period, however an estimated 5–30 percent of CDH cases are considered late-onset (presenting after 30 days of age) and are discovered incidentally on chest x-ray. However, it can occasionally present acutely as a surgical emergency if there is a concurrent gastric volvulus or perforation. This patient had no medical problems through infancy but never re-established paediatric care after moving from another state at age 11 months. Aside from several brief episodes of emesis, he was reportedly asymptomatic until one day prior to his presentation when he presented with symptoms of an acute gastric volvulus. Although rare, this case emphasises the importance of considering atypical presentations of congenital diaphragmatic hernias on the differential diagnosis in patients of any age who present with irritability, tachycardia, tachypnea, chest pain, abdominal pain, or projectile emesis.


Medicine and Health Sciences



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