Vascular diaphragmatic hernia in a patient with cirrhosis first case report

Diaphragmatic hernias appear secondary to structure or insertion abnormalities of the diaphragm and can be divided in two major categories - congenital and acquired hernias. They represent a permanent or temporary displacement of abdominal structures (stomach, spleen, liver, small or large bowel) into the thoracic cavity or a transdiaphragmatic extension of pathological entities, such as a pancreatic pseudocyst and mediastinal or retroperitoneal lipomas (if associated with dehiscence of the diaphragmatic crus or other insertion abnormalities).Congenital hernias have a prevalence in the newborn population of one in 3,000 [1] and can be categorized into three types: posterolateral hernias (Bochdalek); retrosternal hernias (Morgagni-Larrey); and hiatal hernias (embryological mechanisms: septum transversum defects; failed development of the pleuroperitoneal folds; and improper migration of the diaphragmatic musculature) [2]. Acquired diaphragmatic hernias have iatrogenic or post-traumatic etiology, after a significant increase of pressure in the abdominal cavity, such as in the case of a penetrating or blunt trauma (the most common cause) [3]. Situations inducing a moderately increased pressure, such as severe and persistent cough or large ascites, are not usually related to diaphragmatic hernias; however, supplementary pressure can be exerted on abdominal weak points, explaining the herniation of abdominal structures.In our patient, the herniated structure was an anastomotic vessel connecting the left branch of his portal vein and the venous circulation of the left abdominal wall.We present the case of a 45-year-old white man, with a history of alcohol use (100 to 200？mL alcohol/day for more than 20？years), who was recently diagnosed with cirrhosis after an ultrasound examination. An echographic examination was performed prior to his admission to our clinic, which revealed a pseudonodular, inhomogeneous liver with fibrotic changes, an enlarged main portal vein with dec