Can a right-sided small diaphragmatic hernia cause sudden non-exertional chest pain that lasts for moments?

Right-Sided Small Diaphragmatic Hernia and Sudden Non-Exertional Chest Pain

Yes, a right-sided small diaphragmatic hernia can cause sudden non-exertional chest pain that lasts for moments, though this presentation is less common than with left-sided hernias. 1

Pathophysiology and Presentation

Diaphragmatic hernias can present with various symptoms depending on their location, size, and content. Right-sided hernias are less common (12-40% of traumatic diaphragmatic hernias) compared to left-sided hernias (50-80%) due to the protective effect of the liver 1.

The mechanism of pain in right-sided diaphragmatic hernias includes:

• Intermittent herniation of abdominal contents through the diaphragmatic defect
• Transient compression or irritation of thoracic structures
• Visceral ischemia during herniation episodes
• Diaphragmatic irritation from the hernia contents

Clinical Characteristics of Right-Sided Diaphragmatic Hernia Pain

• Often presents as sudden, sharp chest pain that resolves spontaneously
• Pain may be non-exertional and episodic in nature
• Can be confused with cardiac or pulmonary conditions
• May be accompanied by respiratory symptoms in some cases
• Commonly misdiagnosed or delayed in diagnosis (up to 50% of right-sided hernias have delayed diagnosis) 1

Diagnostic Considerations

For patients with suspected diaphragmatic hernia presenting with chest pain:

1. Initial imaging: Chest X-ray (anteroposterior and lateral views) is recommended as the first diagnostic study 1

   • May show abnormal bowel gas pattern, air-fluid level, or hemidiaphragm elevation
   • However, sensitivity is limited (17-33% for right-sided hernias) 1

2. Second-line imaging: CT scan with IV contrast is the gold standard 2

   • Sensitivity of 14-82% and specificity of 87% for diaphragmatic hernias 1, 2
   • Can identify the presence, location, and content of the hernia

3. Special considerations:

   • Listen for bowel sounds in the thorax (diagnostic clue) 3
   • Look for "Dangling diaphragm" sign, "Dependent viscera" sign, or "Collar sign" on imaging 2

Clinical Pearls and Pitfalls

• Important caveat: Right-sided diaphragmatic hernias are often missed on initial evaluation due to their rarity and the protective effect of the liver 1
• Small diaphragmatic defects can cause intermittent symptoms as abdominal contents may herniate and reduce spontaneously 1
• Even small right-sided diaphragmatic hernias can progress to strangulation if left untreated 4
• Symptoms may be present for years before diagnosis, with periods of exacerbation 1

Management Implications

If a right-sided diaphragmatic hernia is suspected as the cause of sudden chest pain:

• Surgical repair is recommended in all cases to prevent complications such as incarceration, strangulation, and bowel necrosis 1, 2
• Laparoscopic approach is preferred in stable patients 2
• Delay in diagnosis and treatment can lead to catastrophic complications 4

In conclusion, while right-sided small diaphragmatic hernias are less common, they should be considered in the differential diagnosis of patients presenting with sudden, non-exertional chest pain of brief duration, especially when other common causes have been ruled out.