Hérnia diafragmática congênita de apresentação tardia: uma possível causa de dificuldade respiratória aguda na criança

Abstract

Objective

To emphasize that congenital defects of the diaphragm should be considered in the differential diagnosis of sudden onset of respiratory distress in children. Method: We report two illustrative cases of children (age: 2 years) with late-presenting congenital diaphragmatic hernia who developed sudden respiratory distress and were treated at the University Hospital of Santa Maria, Brazil. We reviewed the medical literature for case reports and other articles related to late-presenting congenital diaphragmatic hernia, and searched MEDLINE for papers published in the last 25 years. Results: In both cases, the initial clinical examination and plain chest radiographs were misinterpreted as other pleuropulmonary diseases, such as pneumothorax/pneumatoceles. One of the children underwent emergency chest tube placement without clinical improvement. The absence of respiratory symptoms that could justify this kind of pathology motivated a more careful investigation with fiberoptical endoscopy and intestinal seriography. This subsequent investigation revealed that the cause was late-presenting congenital diaphragmatic hernia. Conclusion: Although many patients with late-presenting congenital diaphragmatic hernias have a history of chronic respiratory symptoms, some present with acute symptoms. A higher degree of attention is required to avoid confusion with other intrathoracic conditions, such as pneumatoceles and pneumothorax, and to rule out an incorrect diagnosis. Misinterpretation of chest radiographs is likely when the presence of a congenital diaphragmatic hernia is not suspected, which may result in increased morbidity. Gastric atony may occur in the early postoperative period.

Method

We report two illustrative cases of children (age: 2 years) with late-presenting congenital diaphragmatic hernia who developed sudden respiratory distress and were treated at the University Hospital of Santa Maria, Brazil. We reviewed the medical literature for case reports and other articles related to late-presenting congenital diaphragmatic hernia, and searched MEDLINE for papers published in the last 25 years. Results: In both cases, the initial clinical examination and plain chest radiographs were misinterpreted as other pleuropulmonary diseases, such as pneumothorax/pneumatoceles. One of the children underwent emergency chest tube placement without clinical improvement. The absence of respiratory symptoms that could justify this kind of pathology motivated a more careful investigation with fiberoptical endoscopy and intestinal seriography. This subsequent investigation revealed that the cause was late-presenting congenital diaphragmatic hernia. Conclusion: Although many patients with late-presenting congenital diaphragmatic hernias have a history of chronic respiratory symptoms, some present with acute symptoms. A higher degree of attention is required to avoid confusion with other intrathoracic conditions, such as pneumatoceles and pneumothorax, and to rule out an incorrect diagnosis. Misinterpretation of chest radiographs is likely when the presence of a congenital diaphragmatic hernia is not suspected, which may result in increased morbidity. Gastric atony may occur in the early postoperative period.

Results

In both cases, the initial clinical examination and plain chest radiographs were misinterpreted as other pleuropulmonary diseases, such as pneumothorax/pneumatoceles. One of the children underwent emergency chest tube placement without clinical improvement. The absence of respiratory symptoms that could justify this kind of pathology motivated a more careful investigation with fiberoptical endoscopy and intestinal seriography. This subsequent investigation revealed that the cause was late-presenting congenital diaphragmatic hernia. Conclusion: Although many patients with late-presenting congenital diaphragmatic hernias have a history of chronic respiratory symptoms, some present with acute symptoms. A higher degree of attention is required to avoid confusion with other intrathoracic conditions, such as pneumatoceles and pneumothorax, and to rule out an incorrect diagnosis. Misinterpretation of chest radiographs is likely when the presence of a congenital diaphragmatic hernia is not suspected, which may result in increased morbidity. Gastric atony may occur in the early postoperative period.

Conclusion

Although many patients with late-presenting congenital diaphragmatic hernias have a history of chronic respiratory symptoms, some present with acute symptoms. A higher degree of attention is required to avoid confusion with other intrathoracic conditions, such as pneumatoceles and pneumothorax, and to rule out an incorrect diagnosis. Misinterpretation of chest radiographs is likely when the presence of a congenital diaphragmatic hernia is not suspected, which may result in increased morbidity. Gastric atony may occur in the early postoperative period.

Resumen

Objetivos

Enfatizar que os defeitos congênitos do diafragma devem ser considerados no diagnóstico diferencial da dificuldade respiratória de instalação súbita em crianças.

Métodos

Dois casos ilustrativos de crianças (com 2 anos de idade) com hernia diafragmática congênita de apresentação tardia que desenvolveram dificuldade respiratória aguda e foram tratados no Hospital Universitário de Santa Maria são relatados. A literatura médica foi revisada para identificar relatos de casos e outros artigos relacionados a hérnia diafragmática congênita de apresentação tardia. Uma pesquisa computadorizada foi realizada com o uso do banco de dados do MEDLINE para identificar as publicações editadas nos últimos 25 anos.

Resultados

Em ambos os casos, a avaliação clínica inicial e as radiografias simples de tórax foram interpretadas erroneamente como outras doenças pleuropulmonares, tais como pneumotórax e/ou pneumatocele. Uma das crianças foi submetida a drenagem de tórax emergencial sem melhora clínica. A ausência de sintomatologia respiratória prévia que justificasse esse tipo de patologia motivou uma investigação mais cuidadosa, com fibroendoscopia e serio-grafia gastrintestinal. Essa investigação subsequente mostrou que a causa era hérnia diafragmática congênita de apresentação tardia.

Conclusão

Ainda que muitas hérnias diafragmáticas que se manifestam tardiamente tenham sintomas respiratórios crônicos, algumas se apresentam agudamente. Uma maior atenção é necessária a fim de evitar confusão com outras patologias intratorácicas como pneumatocele e pneumotórax, para que um diagnóstico incorreto possa ser evitado. Uma interpretação errônea das radiografias é provável se a possibilidade de hérnia diafragmática não for considerada, o que poderia resultar em aumento da morbidade. A atonia gástrica pode ocorrer no período pós-operatório imediato.