Pediatric emergency medicine trisk 1028

FIGURE 124.12 A 4-year-old boy admitted with 1-day history of recurrent severe upper
abdominal colicky pain with dyspnea and decreased breath sounds in the left base.
Posteroanterior (A ) and lateral (B ) chest films demonstrate multiple bowel loops in the lower,
posterior, left side of chest, indicative of a foramen of Bochdalek hernia that was subsequently
repaired without difficulty.

Diaphragmatic Eventration
Eventration is an abnormal elevation of one or both hemidiaphragms, and may
present to the emergency clinician as an unexpected finding on a chest radiograph
obtained for another reason. Eventration may be congenital or acquired. Acquired
diaphragmatic eventration is commonly the result of a phrenic nerve paralysis,
which may be caused by birth, operative, or other trauma. Neoplastic or
inflammatory processes in close proximity to the phrenic nerve can also lead to
eventration.
Diaphragmatic eventration occurs most commonly on the left side, but may be
bilateral. The affected hemidiaphragm moves paradoxically during inspiration
and expiration, with compromise of pulmonary mechanics and function. A large
enough congenital eventration may affect prenatal and postnatal lung
development, potentially resulting in pulmonary hypoplasia.
Clinical Recognition


Patients with eventration are often asymptomatic, but may exhibit respiratory
distress as a result of alveolar hypoventilation and paradoxical diaphragmatic
movement. This frequently manifests as tachypnea, pallor, and feeding
difficulties. Physical examination findings of nonaerated lung, including absent
breath sounds and dullness to percussion, should be investigated by chest
radiograph. Chest radiographs usually confirm the presence of an elevated
hemidiaphragm (Fig. 124.14 ). This finding may be confirmed by fluoroscopy or
ultrasound, which will demonstrate paradoxical motion of the hemidiaphragm and
mediastinal shift with inspiration and expiration.

Management
Minor, asymptomatic eventrations may be observed. The need for repair is based
on the severity of the eventration and the degree of pulmonary dysfunction.
Treatment consists of plication of the attenuated portion of diaphragm, and can be
performed thoracoscopically or via open thoracotomy. In selected cases of
acquired diaphragmatic dysfunction due to phrenic nerve paralysis, an implanted
pacemaker can be used to stimulate the phrenic nerve and produce diaphragmatic
motion.

Paraesophageal Hernia
A paraesophageal hernia is a form of hiatal hernia in which the stomach and
potentially other intra-abdominal organs protrude through the esophageal hiatus.
It is uncommon in children, and may be congenital and/or associated with other
anomalies.
Clinical Recognition
A paraesophageal hernia typically presents with symptoms of respiratory distress,
vomiting, and failure to thrive. Symptoms of upper abdominal pain, tachypnea,
and tachycardia may accompany the condition as the herniated stomach distends
with swallowed air inside the chest. Such symptoms may also be indicative of
gastric volvulus, strangulation, and necrosis, although these findings are
uncommon in children with paraesophageal hernia.


FIGURE 124.13 Diaphragmatic defects in infants and children. The nature of these defects are
often better appreciated on a lateral view of the chest. Eventration of the diaphragm (A );
foramen of Morgagni hernia (B ); and left foramen of Bochdalek hernia (C ).

Physical examination may reveal decreased breath sounds and dullness to
percussion over the left chest if a significant amount of abdominal viscera has
migrated into the chest. Rarely, herniation of colon or small bowel may result in

bowel sounds heard over the left lower chest. Upright chest radiographs may
show an air- and fluid-filled mass in the left lower chest, which should be
particularly evident on the lateral view.
Management
Respiratory distress should be appropriately addressed and the patient should be
fluid resuscitated. Attempts should be made to place a nasogastric tube to
decompress the stomach in the patient with associated respiratory compromise or
abdominal pain, but may be difficult or impossible because of angulation of the
gastroesophageal junction (Fig. 124.15 ). Surgical consultation should be sought
because urgent operative intervention may be necessary if the patient has signs of
obstruction or strangulation. If symptoms are significant or if concern for
strangulated viscera exists, patients should be admitted to the inpatient ward for
observation and acute management. Symptomatic paraesophageal hernias warrant
surgical repair, which can be done via laparoscopic or open abdominal approach.

CHEST WALL TUMORS
CLINICAL PEARLS AND PITFALLS
Many chest wall tumors are discovered incidentally by caregivers or on
routine chest imaging.
Over half of chest wall neoplasms in children are malignant.
Chest radiographs and cross-sectional imaging such as CT and MRI
are helpful initial diagnostic modalities.