Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 6  |  Page : 763-765  

Right-sided intra-thoracic kidney associated to Bochdalek hernia in an adult patient


1 Department of Digestive Surgery, Military Hospital, Robert Picqué, 351 Route De Toulouse, 33000 Bordeaux, France
2 Department of Digestive Surgery, Military Hospital Desgenettes, 69000 Lyon, France
3 Department of Radiology, Military Hospital Desgenettes, 69000 Lyon, France

Date of Web Publication19-Nov-2015

Correspondence Address:
Julien Jarry
Department of Digestive Surgery, Military Hospital, Robert Picqué, 351 Route De Toulouse, 33000, Bordeaux
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.169919

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  Abstract 

Diaphragmatic hernia of Bochdalek (BH) and intra-thoracic kidney (IK) are both rare congenital, developmental anomalies. In some extremly rare occasion, these two congenital anomalies can be associated in the same patient. The kidney typically exits the retroperitoneal space through the foramen of Bochdalek. The majority of IK and BH are discovered incidentally. A conservative approach can be proposed in asymptomatic cases. In this report, the case of a 35-year-old man presenting with 1-week of acute abdominal pain is presented. Chest radiography revealed a posterior mass in the right hemithorax, which was later confirmed by chest computed tomography and magnetic resonance imaging to be a congenital IK associated with a BH.

Keywords: Bochdalek hernia, ectopic kidney, intra-thoracic kidney


How to cite this article:
Jarry J, Nguyen V, Moigne FL. Right-sided intra-thoracic kidney associated to Bochdalek hernia in an adult patient. Med J DY Patil Univ 2015;8:763-5

How to cite this URL:
Jarry J, Nguyen V, Moigne FL. Right-sided intra-thoracic kidney associated to Bochdalek hernia in an adult patient. Med J DY Patil Univ [serial online] 2015 [cited 2019 Dec 14];8:763-5. Available from: http://www.mjdrdypu.org/text.asp?2015/8/6/763/169919


  Introduction Top


Bochdalek's hernia (BH) is a congenital defect in the posterior lateral diaphragm that allows abdominal viscera to migrate into the thorax. BH in adulthood is rather uncommon with only 100 reported cases. [1] Adult patients presenting with BH may have associated congenital defects such as an ectopic kidney. The incidence of BH associated with intra-thoracic kidney (IK) is reported to be <0.25% [2] with only six case reports of concomitant, right-sided IK and BH published in the medical literature thus far. We report herein a new case of right-sided IK associated to BH in an adult patient.


  Case Report Top


A 35-year-old male presented to the emergency room with 1-week of acute abdominal pain located in the right upper quadrant. The pain radiated to the right flank and was associated with vomiting. The patient had no past medical history and was not on any medications. He was a nondrinker but regularly smoked. The pain had decreased at the emergency room with analgesics and anti-inflammatory and the patient was discharged home with a referral to our gastroenterological office. On our examination, 1-week later, there was no tenderness to abdominal palpation, but chest auscultation revealed diminished breath sounds and dullness to percussion on the right lower pulmonary lobe. His temperature was 37.3°C, pulse rate 74/min, and blood pressure 100/70 mmHg. Laboratory tests revealed a normal complete blood count, hepatic profile, electrolytes, and renal function. The urine examination showed the presence of red blood cells without nitrites or proteins. The electrocardiogram analysis did not reveal any cardiac abnormality. A chest radiograph revealed a basal paravertebral mass at the right posterior hemithorax containing a small calcification located between the 10 th and 11 th ribs [Figure 1]. A thoraco-abdominal computed tomography [Figure 2] and magnetic resonance imaging [Figure 3] were performed which revealed a right-sided BH with partial hepatic herniation associated with an IK. No abdominal abnormalities were observed. The computed tomography also revealed the presence of a lithiasis in the right kidney. Right renal colic was thought to be the cause of the previous acute pain at the emergency room. In regards of the small size of the hernia and considering the absence of complications on an intravenous urography [Figure 4], a conservative treatment was proposed to the patient. The patient was followed-up every year with a thoraco-abdominal computed tomography and a biological evaluation of the renal function. No renal complication occurred during this follow-up. The patient was lost after 2 years.
Figure 1: Chest X-ray fi lms revealing a basal paravertebral ill-defi ned mass of the right posterior hemithorax containing a small calcification (arrows) located between the 10th and 11th ribs

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Figure 2: Axial computed tomography scan at the cardiac level demonstrates the intrathoracic kidney (in the right hemithorax) containing a renal lithiasis

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Figure 3: Lateral and frontal views of magnetic resonance imaging showing the ectopic right kidney and the liver herniated into the Bochdalek's hernia (arrow)

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Figure 4: Intravenous urography confirming the intrathoracic location of the right kidney and the absence of renal or ureteral anomaly

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  Discussion Top


BH is a congenital defect in the posterior lateral diaphragm that allows abdominal viscera to migrate into the thorax. The defect results from a failed closure of the pleuroperitoneal ducts at about 8 weeks gestation. BH in adulthood is rather uncommon with only 100 reported cases. Considering asymptomatic, prevalence in the general population may be as high as 0.17%. [1] It occurs on the left side in approximately 80% of cases. [1] Adult patients presenting with BH may have associated congenital defects such as an ectopic kidney. IK is a rare developmental anomaly representing <5% of all renal ectopias. Factors that may prevent the orderly movement of the kidney include failed migration of the ureteral bud to the renal fossa or defective metanephric tissue that fails to induce ascent. This condition is common in males and occurs on the left side in 80-90%. The incidence of BH associated with IK is reported to be <0.25% [2] with most of the cases concerning the left side. The incidence of concomitant, right-sided IK and BH is even rarer with only two case reported in adults, [2],[3] three cases in the child [4],[5],[6] and two prenatal case thus far. [7],[8] The kidney typically exits the retroperitoneal space through the foramen of Bochdalek. Some anatomical features of IK are derived from its developmental rotation such as a posterior facing hilum, long ureter, a more proximal origin of the renal vessels, and occasionally medial deviation of the lower pole of the kidney. In spite of these abnormalities, IK is usually fully functional. In all cases, the kidney is located within the thoracic cavity and not in the pleural space. IK associated with BH differs from other intra-thoracic renal ectopias as it tends to be mobile and be easily reduced from the thorax to the retroperitoneal cavity. The majority of IK and BH are discovered incidentally, such as when a child or adult is in surgery or has an X-ray for another medical condition. While surgery is frequently needed for symptomatic or complicated BH, a conservative approach can be proposed in asymptomatic cases and with small hernias associated with IK, as in the present case. Thus, most IK remain asymptomatic and surgery is only necessary in case of ureteral obstruction or vesicoureteral reflux. In these cases, trans-thoracic repair is the usual choice for right-sided BH with IK because of the presence of the liver. After reduction of the IK in the retroperitoneal space, the diaphragmatic defect is closed by a "tension free" primary suture with nonabsorbable thread. Prosthetic patch are also accepted for larger defects.

In summary, IKs are rare clinical entities that pose many diagnostic and management dilemmas for clinicians. The association of a concomitant, right-sided BH and an intra-thoracic renal ectopia is very rare in adult patients. It is emphasized that this condition should be kept in mind in the differential diagnosis of a lower intra-thoracic mass and that the surgical management should be reserved only for the rare, complicated cases.

 
  References Top

1.
Brown SR, Horton JD, Trivette E, Hofmann LJ, Johnson JM. Bochdalek hernia in the adult: Demographics, presentation, and surgical management. Hernia 2011;15:23-30.  Back to cited text no. 1
    
2.
Donat SM, Donat PE. Intrathoracic kidney: A case report with a review of the world literature. J Urol 1988;140:131-3.  Back to cited text no. 2
    
3.
Onuk Ö, Tas T, Sentürk AB, Sinanoglu O, Balci MB, Çelik O, et al. Right-sided Bochdalek hernia with intrathoracic ectopic kidney in an advanced-age adult: A case report. Urol Int 2014;93:368-70.  Back to cited text no. 3
    
4.
Subramanian VS, Goldfarb DA. Right-sided intrathoracic renal ectopia with Bochdalek's hernia. Urology 2008;72:1016-7.  Back to cited text no. 4
    
5.
Karaoglanoglu N, Turkyilmaz A, Eroglu A, Alici HA. Right-sided Bochdalek hernia with intrathoracic kidney. Pediatr Surg Int 2006;22:1029-31.  Back to cited text no. 5
    
6.
Kayiran PG, Gumus T, Kayiran SM, Bilge I, Gurakan B. Ectopic intrathoracic kidney with right-sided congenital diaphragmatic hernia. J Pediatr 2013;163:1226.e1.  Back to cited text no. 6
    
7.
Obatake M, Nakata T, Nomura M, Nanashima A, Inamura Y, Tanaka K, et al. Congenital intrathoracic kidney with right Bochdalek defect. Pediatr Surg Int 2006;22:861-3.  Back to cited text no. 7
    
8.
Masturzo B, Kalache KD, Cockell A, Pierro A, Rodeck CH. Prenatal diagnosis of an ectopic intrathoracic kidney in right-sided congenital diaphragmatic hernia using color Doppler ultrasonography. Ultrasound Obstet Gynecol 2001;18:173-4.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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