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Case of the Month 4/08

The reading of the chest x-ray below included rounded density projecting over the posterior aspect of the left hemidiaphragm is stable and may represent a Bochdalek hernia.
Q1: What exactly is a Bochdalek hernia?

Q2: What could be done next to further elucidate the etiology of this finding?

View answer

Answer 1:

A Bochdalek hernia is a defect in the diaphragm through which abdominal contents may protrude. It may be caused from incomplete closure of the foramina of Bochdalek (# 3 below on the schematic of the pediatric diaphragm below).

Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed.

It is usually seen on the left hand side and appears on x-ray as a smooth rounded structure protruding from the middle region of the diaphragm on the AP view and above the posterior costophrenic angle on the lateral view. Its appearance may change due to amount of protrusion of tissue at the time the x-ray is taken.

Answer 2:

CT, MRI or Barium swallow could be used to help clarify the exact nature of this x-ray finding. In this patient, an MRI revealed the mass to be clearly separated from the muscle of the diaphragm and also separate from the intra-abdominal contents. Because the tissue was consistent in appearance with subcutaneous fat, the lesion was thought most likely to be a diaphragmatic lipoma.