THORACOSTOMY, PLEASE? MASSIVE DIAPHRAGMATIC HERNIA MASQUERADING AS COMPLEX PLEURAL EFFUSION

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dyspnea is defined as a patient's experience of his or her own breathlessness and powerful clue an underlying pathology that may not be confined to the cardiopulmonary system. Gastrointestinal often overlooked etiology intrathoracic unusual cause respiratory symptoms (1). Hiatal hernias rarely present dyspnea are usually seen on plain chest radiograph retrocardiac opacity with air fluid level (2,3). We report case left hemithorax opacification suspicious for large loculated pleural effusion in fact represented diaphragmatic herniation abdominal contents. CASE PRESENTATION: A 97-year-old female history hiatal hernia gastroesophageal reflux disease (GERD) presented hospital from assisted living facility confusion. As part evaluation, X-ray (CXR) was obtained which showed associated incomplete collapse lung (Figure 1). This further investigated computed tomography (CT) large, complex left-sided 2A) pulmonary service asked evaluate patient. On review previous studies, oral-contrast CT done contents above diaphragm thoracic cavity - confirming presence paraesophageal 2B). No surgical intervention offered nor additional work-up needed abnormality observed CT. DISCUSSION: Although common, studies suggesting prevalence 50% people 50 years older (3), it results dyspnea, becoming symptomatic only significant size resulting atrial compression and/or decreased compliance (3). highlights importance independent evaluation imaging, especially if "official" read does seem fit clinical scenario. Likewise, longitudinal comparison imaging paramount establishing chronicity nature encountered should consistently avoid incorrect diagnoses potentially unnecessary procedures. CONCLUSIONS: Herniation form common adults but manifests dyspnea. Diagnosis established basis specific combination radiographic findings. If misinterpreted, initially this case, appropriate treatment delayed unwarranted procedures performed. Clinicians must interpret independently accounting context perform assessment prior arrive at correct diagnosis. REFERENCE #1: Prevalence Among Hospitalized Patients Time Admission. Jennifer P. Stevens, MD, MS, Tenzin Dechen, Richard Schwartzstein, Carl O'Donnell, ScD, Kathy Baker, RN, MSN, Michael D. Howell, MPH, Robert B. Banzett, PhD. Journal Pain Symptom Management. 2018 July; Vol. 56 No. 1: 15-22. #2: Hernia: An presentation Seied Ahmad Mirdamadi, Mahfar Arasteh, MD. N Am J Med Sci. 2010 Aug; 2(8): 395-396. #3: When Stomach Rules Heart: Neglected Complication Large Hernia. Thomas H. Marwick, MBBS, Americal College Cardiology. 2011 October 58 (15): 1635-1636. DISCLOSURES: relevant relationships by Christine Girard, source=Web Response Daniel Kotok,