Up to the chest in bowels: case of strangulated right diaphragmatic hernia with paraesophageal hernia in a non-trauma patient.

A Bochdalek hernia is a rare congenital diaphragmatic hernia often diagnosed in infancy and classically occurring on the left side. We report a case of a 78-year-old female who presented with a right-sided posterolateral diaphragmatic hernia containing multiple loops of bowel with evidence of ischemia as well as a type 4 paraesophageal hernia. The stomach was rotated on the organoaxial plane, and the duodenum was within the mediastinum. The patient was taken emergently for an exploratory laparotomy. A posterolateral hernia defect containing 50 cm of strangulated small bowel was identified and resected, a primary stapled enteroenterostomy was performed and the hernia defect was repaired primarily. The stomach was reduced, a primary crura repair was performed, and gastropexy was performed with a gastrojejunostomy tube. The patient was transferred to the intensive care unit, and subsequently extubated, enteral feeds were initiated, and had anticipated discharge to a skilled nursing facility. This case highlights an uncommon atraumatic presentation of an adult with a congenital diaphragmatic hernia. Its rarity is further denoted due to its right-sided laterality and strangulated small bowel as the usual herniated abdominal organs are the liver or colon.