Unusual Presentation of Congenital Diaphragmatic Hernia in Six-Years-Old Boy

Six years old boy has been admitted at the pediatric department of regional hospital because of high body temperature, productive coughing and general deterioration. Chest X ray has been made (Picture No 1), and thoracic drainage has been done because of suspicious pleural effusion. Initially, serous fluid was drained, later it became hemorrhagic. Intravenous antibiotics were administered. In spite of all undertaken measures, general condition of patient has further deteriorated: patient had fever, and was somnolent, has been vomiting repeatedly, and, as emergency case, was transported to Mother and children health institute of Serbia, in Belgrade. On admission boy was febrile, adynamic, tachycardic, tachypnoic, pale, sweating, with diffuse tenderness of abdomen on palpation. On chest auscultation, breathing sounds were absent on basal left side. Nasogastric tube was introduced, and chest X-ray (Picture No 2) as well as prone abdominal film was made (Picture No 3). It was obvious that gastric tube is placed in left hemithorax, and that abdomen was gasless. These findings suggested that the ventricle was placed in left hemithorax, and, gaslessness of the abdomen suggested possible peritonitis. Conclusion was that boy has had congenital diaphragmatic hernia, and possible perforation of some digestive organ. After preoperative preparation, surgery has been performed: after the reposition of organs from hemithorax, perforation of front gastric wall was found, and immediately sutured. Diaphragmatic defect was reconstructed, and concomitant intestinal malrotation solved by Ladd procedure. Intervention was finished by double drainage of left hemithorax, and peritoneal cavity. Postoperative course was without any complication, and the patient has been discharged from hospital in good condition on tenth postoperative day. Congenital diaphragmatic hernia is an anomaly which is the most frequently found in newborn period, but in 10-20% of cases is found later in childhood. That should be the reason to be aware and consider this anomaly in all age groups. UNUsUaL pREsENTaTIoN oF CoNGENITaL DIapHRaGMaTIC HERNIa IN sIX YEaRs oLD BoY