Bochdalek hernisi

Özet

Bochdalek hernisi, diyaframın posterolateral kesimindeki konjenital açıklıktan abdominal yağ veya organların toraksa uzanmasıdır; erişkinde tesadüfen saptanabilir. BT, defektin arka-lateral konumunu ve herni içeriğinin retroperitoneal ya da peritoneal devamlılığını gösterir. Bağırsak içeren hernilerde aynı inceleme tıkanma ve dolaşım bozukluğu bulgularını araştırmaya da yarar. Konjenital posterolateral Bochdalek hernisi ile travmatik diyafram yırtılmasının ayrımı önemlidir; BT herni tipini ve eşlik eden komplikasyonları tanımlayarak cerrahi planlamaya katkı sağlar.

Faz ve pencere

Portal tanısal

Aksiyel ve koronal kontrastlı BT'de posterolateral diyafram açıklığından geçen yağın, bağırsak ansının, dalağın veya böbreğin yeri ve abdominal devamlılığı izlenir; bağırsak içeriğinde duvar kontrastlanması, kese içi sıvı ve tıkanma bulguları değerlendirilir.

Önerilen pencereler: Yumuşak doku (G 400 / M 40), Batın (G 400 / M 50), Akciğer (G 1500 / M -600).

BT bulguları

• Posterolateral defekt — diyaframın kostal ve lomber kısımları arasındaki arka-lateral açıklıktan toraksa geçiş.
• Toraksa uzanan yağ — retroperitoneal veya peritoneal yağın kas düzlemini geçip posterior kostofrenik alana ulaşması.
• Herni içeriğinde bağırsak — toraks içinde gaz veya sıvı içeren ansın abdominal anslarla kesintisiz devam etmesi.
• Dalak veya böbrek yer değiştirmesi — sol tarafta dalak, böbrek ya da çevre yağın posterolateral defektten yukarı uzanması.
• Akciğer basısı — herni kesesinin komşu alt lobu öne veya mediale itmesi ve bazal hacim kaybı oluşturması.
• Herniye anslarda tıkanma — boyunda kalibrasyon değişikliği, proksimal dilatasyon ve distal anslarda kollaps.
• İskemi kuşkusu — herniye bağırsak duvarında azalmış kontrastlanma, duvar ödemi, mezenterik sıvı veya pnömatozis.

Normalde

Normal posterolateral diyafram, toraksı retroperitoneum ve peritoneal boşluktan ayıran kesintisiz kas konturudur; posterior kostofrenik reseste bağırsak, dalak veya böbrek bulunmaz. Koronal planda iki kostovertebral açıdaki diyafram bağlantılarını izleyin ve şüpheli taraftaki organın kas düzlemini aşıp aşmadığını karşı tarafla kıyaslayın.

Ayırıcı tanı

Travmatik diyafram rüptürü torakoabdominal travma sonrasında gelişebilir; BT'de diyaframda segmental kesinti ve bu kesintiden herniasyon görülebilir.

Diyafram eventrasyonu, Bochdalek hernisinden ayrı bir diyafram anomalisidir.

Morgagni hernisi

defekt posterior değil, sternumun hemen yanında anterior ve parasternal konumdadır.

Hiatal herni

mide özofagus hiatusundan posterior mediastene ilerler; posterolateral kas defekti oluşturmaz.

Ekstraplevral yağ yastığı

diyaframın üst yüzünde sınırlı yağ görünür ancak karın yağ dokusuyla defekt boyunca bağlantı ve organ geçişi yoktur.

Tuzaklar

• Küçük yağ içerikli posterolateral herniyi yalnız kesitsel bir yağ adacığı sanmayın; koronal ve sagittal planda abdominal yağla bağlantısını ve kas açıklığını izleyin.
• İnce kesitte diyaframın normal kısmi hacim etkisi defekt izlenimi verebilir; kesinti çok düzlemde doğrulanmıyorsa herni tanısını kesinleştirmeyin.
• Sağ tarafta karaciğer posterolateral diyaframı örtebilir; karaciğerin dış konturunu değil, karaciğer komşuluğundaki kas hattını izleyin.
• Diyafram hernileri konjenital veya sonradan edinilmiş olabilir; edinilmiş olanlar genellikle travma ya da cerrahi sonrası gelişir.

Kendini dene

1. Erişkin BT'sinde sol posterior kostofrenik açıdan toraksa uzanan abdominal yağ ve bağırsak görülüyor. Defektin konumu en çok hangi herniyi destekler?

   • Bochdalek hernisi
   • Morgagni hernisi
   • Hiatal herni
   • Diyafram eventrasyonu
   Cevabı göster

   Bochdalek hernisi. Posterolateral yerleşim Bochdalek açıklığının tipik konumudur. Morgagni anterior parasternal, hiatal herni özofagus hiatusu düzeyindedir; eventrasyonda açıklıktan organ geçişi olmaz.

2. Posterior diyafram komşuluğunda yağ dansiteli odak var, ancak kesintisiz kas çizgisi ve abdomenle bağlantı korunuyor. En uygun yorum hangisidir?

   • Ekstraplevral yağ yastığı
   • Bochdalek hernisi
   • Travmatik rüptür
   • İnkarserasyon
   Cevabı göster

   Ekstraplevral yağ yastığı. Kas çizgisinin korunması ve abdominal yağla bağlantı bulunmaması, defektli gerçek herniden çok sınırlı ekstraplevral yağ yastığını destekler. Diğer seçenekler açıklık, travmatik kas hasarı veya sıkışmış organ gerektirir.

İlgili konular

• Morgagni hernisi
• Travmatik diyafram rüptürü

Kaynaklar

Bu sayfadaki 36 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 4 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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