Strangulated Adult Bochdalek Hernia With Extensive Small Bowel Necrosis and Septic Shock

Bochdalek diaphragmatic hernias are congenital diaphragmatic defects through which abdominal viscera herniate into the thoracic cavity and are typically diagnosed in newborns and infants. Adult presentations are uncommon and may present with heterogeneous manifestations, ranging from asymptomatic to life-threatening complications. A 72-year-old male with a history of urinary retention presented with acute lower abdominal pain and vomiting. Initial physical examination and laboratory studies suggested a urinary tract infection. Despite adequate treatment, the patient’s condition deteriorated, and progressive hemodynamic instability led to the diagnosis of septic shock secondary to intestinal obstruction. Chest X-ray incidentally revealed intrathoracic bowel loops, raising suspicion for a diaphragmatic hernia, while computed tomography confirmed the Bochdalek hernia with strangulated bowel. Emergency laparoscopic exploration identified a 3 x 3 cm diaphragmatic defect with herniated small bowel. Due to irreducible herniation and dense adhesions, the procedure was converted to laparotomy. The defect was enlarged to facilitate reduction, followed by resection of 1.2 m of necrotic small bowel, primary diaphragmatic repair, and bowel anastomosis. The patient recovered and remained recurrence-free after four years. This case underscores that adult diaphragmatic hernias may initially present with nonspecific symptoms in patients with comorbidities that suggest more common diagnoses, sometimes leading to premature diagnostic closure. Prompt reassessment and broad differential diagnosis for patients with clinical deterioration and unclear etiology are key to timely recognition of complicated adult diaphragmatic hernias. Early surgical management can then ensure favorable outcomes even in severe, life-threatening complications.