Intrathoracic Gastric Perforation Due to Late-Presenting Bochdalek Hernia in an Adolescent: A Rare Case of Panvisceral Herniation

Congenital diaphragmatic hernias (CDHs), particularly those of the Bochdalek type, arise when the pleuroperitoneal canal fails to close during fetal development, most often affecting the left posterolateral aspect of the diaphragm. These hernias are typically identified in the neonatal period, making their appearance in adolescence quite rare. When they do occur later in life, they may present with a range of GI or respiratory symptoms, which can complicate diagnosis. A missed or delayed diagnosis, especially in cases involving visceral perforation, can significantly increase the risk of complications and morbidity. A 15-year-old girl presented with a seven-day history of abdominal pain, multiple episodes of vomiting, shortness of breath, and obstipation. Examination revealed diminished air entry and audible bowel sounds over the left hemithorax, raising early suspicion of a diaphragmatic defect. A chest radiograph revealed complete opacification of the left hemithorax. Further evaluation with ultrasonography and contrast-enhanced CT of the thorax and abdomen demonstrated a left posterolateral diaphragmatic defect measuring approximately 9 × 6 cm. Multiple abdominal viscera, including bowel loops, omentum, stomach, spleen, and the pancreatic tail, were found to be herniating into the thoracic cavity, with a significant mediastinal shift to the right. An emergency exploratory laparotomy was performed. The herniated contents were reduced, and both the peritoneal and thoracic cavities were irrigated. A 2 × 2 cm gastric perforation was identified and repaired using Graham's omental patch technique. A 32 Fr intercostal drainage tube was inserted into the left pleural space, and abdominal drains were placed for postoperative management. The patient had an uneventful recovery apart from postoperative pneumonia, which resolved with antibiotics. She was discharged on postoperative day 14 and remained symptom-free on follow-up. This case emphasizes the need for high clinical suspicion and timely surgical intervention in adolescent patients with atypical respiratory or GI symptoms, especially in the presence of thoracoabdominal findings.