Pancreas in the chest: Diaphragmatic hernia with obstruction

Diaphragmatic hernias involving abdominal viscera are uncommon in adults and rarely involve the pancreas. While congenital diaphragmatic hernias (CDH) typically present in infancy, late presentations may occur with non-specific gastrointestinal or respiratory symptoms, often leading to delayed diagnosis. Cross-sectional imaging plays a pivotal role in identifying the extent and contents of herniation, especially in complex or atypical cases. We present a case of A 91-year-old woman with known rectosigmoid adenocarcinoma who presented with abdominal pain, constipation, nausea, and persistent cough. Chest X-ray revealed cystic lucencies within the right hemithorax, associated with blurring of the right hemidiaphragm and relative paucity of bowel gas in the upper abdomen. These findings were concerning for an underlying structural abnormality of the diaphragm. Thoraco-abdominal CT demonstrated a large right diaphragmatic hernia containing the stomach, colonic loops, the body and tail of the pancreas, and mesenteric fat and vessels. Additional findings included colonic dilation and peritoneal free fluid, consistent with large bowel obstruction secondary to malignancy. No history of trauma was reported, favoring a congenital etiology. This case highlights an unusual radiological finding of pancreatic herniation into the thorax through a right-sided diaphragmatic defect. It emphasizes the importance of cross-sectional imaging in diagnosing complex hernias, particularly in elderly patients with overlapping thoracoabdominal symptoms.