Diaphragmatic hernia?

Dear all, this case is causing me headache for the unusual of findings and the lack of supportive history.

Dear all, this case is causing me headache for the unusual of findings and the lack of supportive history.

-BOKKE is a 11 year old, MN, 31.7kg,labrador retriever

-hx: 2 week duration of coughing with a more recent appearance of fresh blood strings in sputum. Normal apetite and no vomiting nor weightloss. BCS 6.5/9. NO HISTORY of TRAUMA recent nor past at all…(this is the weird bit, and the breed…)

-Examination: normal auscultation. No other relevant findings.

-Laboratory findings: owner elected not to do bloodwork for now.

– XRAY: loss of detail of normal diaphragmatic silhouette with soft tissue opacity in the caudo-ventral aspect of the thoracic/mediastinum space. There is a leafy appearance of well aired lung lobes suggestive of mild pleural effusion. There is a mild bronchial/mildly interstitial pattern in peri-hilar aspect and ventral aspect of right middle lung lobes (overlapping with cardiac apex silhouette). There appears to be a shortened distance between gastric fundus silhouette and diaphragm, as well as appearance of a small liver with missing lobes/intra-abdominal hepatic tissue.

– Ultrasound: intercostal approach on left hemithorax, reveals hepatic tissue inside caudal thoracic cavitywith a mild amount of pleural effusion and what appears to be a discontinuation of normal diaphragmatic interface. There appears to be gastric fundus folds in close contact with diaphragm instead of being in contact with hepatic tissue. No pericardial nor cadiac abnormalities were found. No abnormal lung parenchyma is found.

-Questions: do you agree with these findings? could this be hepatinization of lung parenchyma instead? It does not look like that to me neither from scan nor from xrays, but I dont know the diaphragmatic hernia explains the blood in sputum or cough. Could there be a secondary pneumonia/bronchitis? and what would be the pathophysiology behind it?

Thank you for you input.




3 responses to “Diaphragmatic hernia?”

  1. Yes there is a hernia

    Yes there is a hernia there… in older patients always be concerned with hepatic neoplasia eating away at the diaphragm or sliding hernia that may have been stable and then for whatever reason freed up. Check prior rads if available to see if hernia was always there or if its a new thing. I would fna liver in the thorax from intercostal approach and tap the fluid spin down to sediment and look for neoplasia and culture the fluid. If all inflammatory and innocuous then its surgery. The pylorus/duodenum looks like its peeking through the hernia as well and looks inflamed hence the hematemesis.

  2. Thank you Eric. Yes I also
    Thank you Eric. Yes I also think that the stomach seems to be moving inside in certain angles. Actually, during the clips I got the stomach there I could not see the liver as clearly as before, and I was thinking of some degree of dynamism of the herniated organs. This is very helpful. Thank you again for your help.

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