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The aim of Radiology Quiz is to highlight the importance of early investigation and diagnosis of congenital diaphragmatic hernia (CDH) in a neonate.
If diagnosis is made antenatally, then no feeds are given. The neonate in the quiz was diagnosed when breathlessness developed after the first feed and radiographs taken.
As per Wiseman Classification of CDH, Type I (wherein herniation occurs during bronchial branching leading to severe bilateral pulmonary hypoplasia) is uniformly fatal. In Type II (herniation during distal bronchial branching leading to unilateral pulmonary hypoplasia) survival is possible and these are usually picked up in antenatal scans. Type III (herniation in late pregnancy with compression of otherwise normal lung) and Type IV (post natal herniation with compression of otherwise normal lung) show excellent prognosis.
The first priority of treatment for Bochdalek hernias is adequate ventilatory support. Energetic resuscitation includes new techniques such as high frequency oscillation and ECMO which are not available routinely. It is obvious that babies have to be stabilized before surgery for diaphragmatic repair. Early repair is important the decision being made on proper clinical evaluation rather than by defining a time frame in hours.
Surgery has to be performed at the earliest as a definitive treatment for CDH. The abdominal contents must be returned to the abdomen for decompression of the lungs. Associated visceral anomalous vascular supply to spleen or liver have to be evaluated during surgery. It has been found that 39 to 77% survive after repair.
The take home message of the quiz is CDH is a neonatal emergency where early diagnosis is made radiologically (on the basis of radiographs and ultrasonography) and management requires energetic resuscitation and stabilization for definitive surgical repair of the defect at the earliest.