Bochdalek hernia in an octogenarian.

An 81-year-old chronic smoker with known chronic obstructive pulmonary disease (COPD) presented with a 2-day history of dyspnoea and dry cough in January 2012. His oxygen saturation was normal, but physical examination revealed occasional expiratory wheezing and decreased air entry over the right lower zone. The complete blood picture showed no leukocytoses. The patient was initially managed as an infective COPD exacerbation. The chest X-ray (CXR) yielded presence of bowel gas and bowel shadow over the right lower hemithorax, with preservation of the right costophrenic angle in the frontal projection and the posterior costophrenic sulcus in the lateral projection (Fig 1). Without blunting of costophrenic angles and the posterior costophrenic sulci, presence of pleural effusion was unlikely. A right decubitus CXR confirmed no significant pleural fluid was present. A CXR taken 7 years earlier also revealed similar changes but was interpreted as a right-sided pleural effusion. Computed tomography of the thorax with contrast showed the presence of stomach and transverse colon within the right hemithorax (Fig 2) and emphysema. The patient could recall no previous history of major trauma to the abdomen. Based on the history and radiological finding, a right Bochdalek hernia was diagnosed. Owing to his advanced age and poor lung function, the patient declined surgical repair.