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Chest X-ray at presentation (this image is provided by courtesy of Pediatric Clinic, Fachkrankenhaus Hubertusburg, Wermsdorf, Sachsen, Germany).
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The initial chest X-ray showed a left-sided tension pneumothorax with mediastinal shift and the suspicion of bowel loops in the left lower hemithorax ( Fig. 1 ).
Thoracic CT scan on admission: left-sided tension pneumothorax with mediastinal shift. No further signs of a traumatic etiology.
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After immediate endotracheal intubation, a thoracic computed tomography (CT) scan was performed, which confirmed a left-sided enterothorax with mediastinal shift ( Fig. 2 ).
Chest X-ray at 1-year of age with no signs of diaphragmatic hernia.
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Due to the sudden onset of symptoms and a normal chest X-ray which was available from the age of 1 year ( Fig. 3 ), a diaphragmatic rupture was considered as a differential diagnosis.
Diagnostic laparoscopy: herniation of stomach, spleen and bowel into the chest.
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Bochdalek hernia was detected with herniation of the small intestine, spleen, and stomach into the chest ( Fig. 4 ). Bile-stained fluid was found in the thorax and abdomen.
Gastric perforation after repositioning of herniated organs into the abdomen.
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After repositioning of the herniated organs into the abdomen, a gastric perforation at the lesser curvature was detected ( Fig. 5 ), explaining the pneumothorax.