Bochdalek´s Diaphragmatic Hernia, Incarceration vs. Middle Lobe Pneumonia
Left picture: The diagnosis is a congenital diaphragmatic hernia (Bochdalek´s hernia) of the left side, which has had no clinical manifestation in the neonatal period, but only recently due to an incarceration of a part of the transverse colon in the diaphragmatic defect. Notice the interrupted contour of the left diaphragm in the plain abdominal x-ray, and the shape of the contrast stop in the enema, which does not correspond to the form of an intussusception. Right picture: As the cause of the supposed abdominal emergency, a middle lobe pneumonia was found on the right side. The careful history and clinical examination resulted in an indication for chest x-rays which confirmed the clinical differential diagnosis of ´pneumonia´. Depending on the history and the follow-up, a cause of this type of pneumonia must be found; for instance, a former aspiration of a foreign body or a bronchus adenoma. Both cases illustrate that pathologies close to the abdomen (e.g. congenital diaphragmatic hernia), as well as extraabdominal lesions (e.g. pneumonia or acute scrotum) - pediatric surgical and pediatric disease entities - have to be considered in the differential diagnosis of a surgical abdomen.
Left picture: Surgical abdomen in a toddler. Plain abdominal x-ray in upright position showing severely dilated intestinal loops. The loop running from the left upper to the right lower abdomen is grotesquely dilated. In the right lower abdomen there is an indication of an air-fluid level. A contrast enema displays a stop in the left upper belly which has a rounded border in the cranial direction, not having one of the typical shapes observed in intussusception (look at the picture at the bottom on the left side). What pathology is demonstrated? Right picture: Acute abdominal emergecy in a schoolchild. Because the distinct abdominal pain is combined with respiratory signs, chest x-rays in two planes are performed as an additional examination, which are shown in the picture at the top and at the bottom on the right side. What is the cause of the abdominal emergency?