Interesting Case No.6

Diaphramatic Hernia - Charlie's Story

Charlie was a 6 year old cat who presented to our clinic with lethargy and breathing difficulties. On examination Charlie was found to have pale gums and dyspnoea. Dyspnoea means “difficulty with breathing”. He was immediately admitted for radiology. The X-Rrays revealed that there was a large amount of fluid in his chest (pleural effusion), compressing his lungs and making it difficult for him to breath.

Pleural effusion: There are many reasons for fluid filling in the pleura, the space between the lungs and the chest wall. Whatever the reason, the most important thing is to drain the fluid away, as these patients often die very quickly. It can be hard to diagnose problems within the chest until such time as the fluid is drained away, and clearer X-Rays can be taken.

Under sedation Charlie had 120ml of fluid drained from his chest. Often we can tell a lot from the sort of fluid that is drained. We may get pus from infectious causes, blood from trauma or certain types of cancers, or a straw coloured fluid which could have many origins. In Charlie's case we obtained a straw coloured fluid. Once drained we could re X-Ray and get a better clue as to what may be causing this problem.

Ordinarily a clear chest should show a clear line of demarcation where the diaphragm separates the chest cavity from the abdominal cavity. In Charlie's case this line was very blurred. This often happens with diaphragmatic hernias. A diaphragmatic hernia occurs when there is a tear in this muscle. Often contents from the abdomen can then enter the chest cavity and cause problems. These problems may range from very subtle without any real clinical signs, to potentially life threatening within hours.

Diaphragmatic Hernias: these usually occur secondary to trauma, such as being hit by a car, and if they occur abdominal contents may enter the chest cavity. All suspect hit by car accidents should have their chest X-Rayed, as sometimes there are no signs of illness at all until possibly weeks, months or even years later when a slowly building problem suddenly manifests itself. Other patients can die within minutes or hours of sustaining a diaphragmatic hernia. It has been known for apparently healthy cats to die under anaesthetic, only for an autopsy to reveal a long standing diaphragmatic hernia. Subsequent questioning often has a client recalling their cat being hit by a car some years earlier but radiology was either not offered by the veterinarian, or refused by the client because the cat “seemed well” at the time!

We decided to perform an exploratory laparotomy to see if Charlie had a diaphragmatic hernia, due to the suspicion on radiology. It was in fact revealed that there was a large hernia with a large portion of liver having entered the chest cavity. At this point of time we felt we had not only our diagnosis, but a potentially correctable injury. This situation often leads to fluid build up in the chest, which once corrected, with the diaphragm closed, carries a good prognosis for full recovery.

However, not all surgeries go to plan, not all illnesses are as they first seem! Strangely, the liver was very strongly adhered to the heart! Although experienced, the 2 surgeons involved in this case had never come across such a situation, and we had difficulty trying to separate the very delicate liver tissue from the heart, it was so strongly attached. Although such difficult cases are often referred by general practice to specialist surgeons, fortunately at Southern Vets we have Dr Karin Davids who performs many of the more difficult and unusual surgical cases. She was bought into this surgery and although never having seen such a case herself, was able to slowly separate the liver successfully and return it the the abdomen and close the diaphragm successfully.

However: our concern when we had dissected and separated the liver from the heart was that there was a “pseudo-membrane” that had 'walled' off the extended abdominal cavity from the chest cavity. Again we had never come across such a situation. Our concern was that we couldn't really see how this situation could lead to the fluid build up in the chest. Upon completing the surgery, Charlie was re X-Rayed and now that we could get a clearer picture, we could see a suspicious area in the caudal chest cavity that the previous diaphragmatic hernia was obscuring. We hoped this may just be scarring from the long term hernia. We had decided that this hernia must have been very long standing to have been the way it was, probably very many years. We were now unsure whether this was actually causing the lung fluid problem or not.

The options from here were:
Wait and see how Charlie recovers, and if the fluid returns or not.
MRI to gain further information as to the nature of the lung shadow.

Due to costs the owner decided to wait and see. Unfortunately Charlie's lungs began to fill with fluid again over the course of the week and he deteriorated. This was now confirmation the hernia was not causing the problem. Most likely Charlie had a lung tumour. There was the option of MRI or further exploratory surgery and removal of a tumour if found, but the prognosis for such a concern is that this may or may not save Charlie. Due to the potential costs and the “guarded” prognosis of getting a long term result, the owners decided to put Charlie to sleep.

Although a very interesting case, the outcome was not favourable to Charlie. Both with humans and our pets, we cannot always get a favourable outcome. However, although further surgery may or may not have been successful, we continue to urge all clients to get their pets insured so that in similar circumstances costs won't be part of the decision making.