A Rare Cause of Palpitations

An 87 years lady presented to the Acute Medical Unit with palpitations and breathlessness. She was haemodinamically stable and ECG was normal in sinus rhythm but cardiac monitoring demonstrated runs of atrial fibrillation. Bloods including TSH were normal. CxR (Figure 1) demonstrated opacity in Right Lower Lobe. A CTscan(Figure 3 and Figure 4) and Echocardiogram (Figure 2) was undertaken.

The CT scan showed a large posterior diaphragmatic hernia containing spleen, stomach and tail of pancreas.

Common cause of diaphragmatic hernias in adults are trauma, congenital defect in the diaphragm, iatrogenic injury during abdominal or thoracic surgery and factors increasing intra-abdominal pressure such as pregnancy, child birth, coughing and sneezing.

The majority of Bochdalek hernias are asymptomatic and are usually incidental findings. Symptoms are depending on the defect size and hernia contents and can be pulmonary, gastrointestinal and rarely cardiac.

The major complication is strangulation of the herniated contents, as this is associated with mortality of over 80%.This represents a surgical emergency and requires prompt diagnosis and surgical repair.

Our case could be managed with symptoms control with Bblockers or Diltiazem.

Surgery is required in strangulation and very symptomatic hernias, small defects are easier to repair whereas larger defects may involve reduction of intraabdominal contents.

Echocardiogram showed a large extra cardiac structured below the left atrium which was the spleen.