Well done on your answers! The chest xray that you saw showed a L sided hiatal hernia – the left diaphragm is not visible while the right is. The bowel loops have crossed the midline (with an air bubble on top of the right heart border) and can be seen extending into the R hemithorax as well. You all probably wanted to get a Lateral xray…great though to differential an anterior/middle/posterior mediastinal mass.
The patient had further imaging done, a CT which revealed multiple loops of bowel that were located posterior to the heart and had filled the space normally occupied by the lungs. See image below:
Thank you Anurag Mehta for the great case and images.
Our Pulmonogist and ICU director, Dr. Kershaw gave us a lecture on July 18 discussing mediastinal masses on imaging giving us a nice list. He says: “remember that lateral chest xrays can help you differentiate middle mediastinal masses, one of which is a hiatal hernia.”
Excerpt from his slides:
And for BONUS: remember the 2 types of Congential Diaphragmatic Hernias (CDH)?
CDH is usually 95% posterolateral (Bochdalek hernia), but may be anterior retrosternal or peristernal (Morgagni hernia), or rarely central. ***mnemonic: Bochdalek is back and to the left***
Come back soon for another #FridayImageChallenge!