Challenges in Managing a Congenital Strangulated Bochdalek Hernia in an Older Female Patient in a Low-Income Country: A Case Report.

Introduction: Bochdalek hernias are the most common type of congenital diaphragmatic hernia. They can remain asymptomatic throughout life. Occasionally, however, they are discovered when complications arise, such as respiratory distress due to strangulation or volvulus of herniated organs. A late diagnosis is common due to their rarity in older adults. This condition needs early diagnosis, treatment, and strong supportive care to save the patient's life. In this study, we discuss the specific challenges encountered when managing a congenital strangulated Bochdalek hernia in an older female patient in our tertiary healthcare centre. Case Presentation: We present the case of an 88-year-old Black woman who was admitted to our emergency department in October 2021. She had a history of epigastric pain and hypertension. She was admitted for dyspnoea, constipation and abdominal pain lasting 24 h. At this time, it was a unique diagnostic we suspect due to the epidmiology context. Initial investigations included a rapid COVID-19 test, a PCR test for COVID-19, and a chest X-ray. The former two were negative, but the latter showed a gastric pocket in the left chest. We suspected a diaphragmatic hernia. The following day, the patient underwent thoracoabdominal computed tomography, which revealed a left diaphragmatic hernia with signs of intestinal necrosis, suggesting strangulation. An electrocardiogram showed sinus tachycardia, and an ultrasound revealed a heart with normal left ventricular function. The patient underwent emergency laparotomy, which revealed intestinal necrosis. The spleen was found to be lacerated, and the stomach had ascended into the left thoracic cavity. The gangrenous ileum was resected with loop stoma formation, the spleen was removed, and the hernia orifice was repaired by interrupted stitches. Unfortunately, the patient died on the fourth post-operative day due to Multiple Organ Dysfunction Syndrome. Conclusion: Strangulated Bochdalek hernia is a rare emergency condition with non-specific signs. It requires rapid and comprehensive investigation to avoid delays in diagnosis. Surgery is the definitive treatment. In older adults, successful management depends on the presence of morbidities that may not be fully addressed before surgery, intensive and rapid perioperative resuscitation, and emergency surgery. The triage process during the pandemic may also have contributed to a worse prognosis, especially in low-income countries.