case_images: PMC9911423_01
case_images: PMC9911423_02
case_images: 67-year-old man of BMI 42.5 who failed SLIH conservative management: the diagnostic and follow-up radiological pathway is shown. At first presentation, a chest x-ray (A) and CT abdomen were done to investigate for abdominal and lumbar pain: the defect was not evident at the x-ray and not described on the CT report (though being visible at the scan images). A large known hiatus hernia was reported at CT containing almost the entire stomach (with no signs of obstruction/strangulation) and the midportion of the body of pancreas. The patient presented again after 8 days with a second episode of acute pain and was admitted in the hospital: a new chest x-ray and CTPA (B) recorded an atelectasis of the lingula and suspicion for infection/aspiration. The herniation of the right lower lobe was still not visible at the x-ray, but it was characterized at the CTPA (B) and addressed as the possible cause of pain in the report. At repeat radiological evaluation for the new onset of shortness of breath 3 weeks after first presentation, the herniation of the right lower lobe was partially visible at the x-ray (C). The CTPA described an acute fracture of the right lateral eighth rib with associated lung contusion and atelectasis and small focal anterior right pneumothorax (D).
case_images: fsurg-09-1091727-g001.jpg
case_images: PMC9911423_02_fsurg-09-1091727-g001.jpg
case_images: F1
case_images: He reported a 2-week history of non-productive cough, and his radiological imaging was suggestive of a community-acquired pneumonia (Figure 1A). After a full chest radiological evaluation, he was admitted for further treatment of the suspected lower respiratory tract infection (LRTI) with CT chest showing a right lung herniation through the 8th intercostal space (Figure 1B). After 3 weeks from the first presentation, the herniation of the right lower lobe was partially visible on x-ray (Figure 1C). Upon CT pulmonary angiography (CTPA), an acute fracture of the right lateral 8th rib with associated lung contusion and atelectasis was described along with a small focal anterior right pneumothorax (Figure 1D).
case_images: PMC9911423_03
case_images: PMC9911423_04
case_images: 36-year-old man, BMI 40.3, with a left SLIH presenting with extensive bruising, abdominal pain, and shortness of breath. (A) chest x-ray at presentation showed an subcutaneous emphysema within the left axillary region and supraclavicular fossa. (B) CTPA revealed a moderate left pneumothorax without tension, a left abdominal wall and neck subcutaneous emphysema, left effusion, and a displaced fracture of the left lateral 8th rib. Lung herniation was not reported; however, on a retrospective review, a small left-sided lung hernia could be identified. (C) A CT scan revealed a herniation of a small lingula portion, abdominal fat, and lateral aspect of the diaphragm, and old rib fractures of the 6th lateral rib, 7th non-united lateral rib with a 15-mm gap, and 8th posterior rib with callus formation with displacement of the anterior portion of the eighth rib more anteriorly with a wide separation of the distracted fragments.
case_images: fsurg-09-1091727-g002.jpg
case_images: PMC9911423_04_fsurg-09-1091727-g002.jpg
case_images: F2
case_images: At chest x-ray, subcutaneous emphysema was seen (Figure 2A). Lung herniation was not reported; however, a small left-sided lung hernia could be identified on retrospective review (Figure 2B). An updated chest CT scan revealed herniation of lingula, abdominal fat, and lateral aspect of diaphragm (Figure 2C).
case_images: PMC9911423_05