Published online Apr 27, 2022. doi: 10.4254/wjh.v14.i4.854
Peer-review started: November 20, 2021
First decision: January 12, 2022
Revised: February 3, 2022
Accepted: March 26, 2022
Article in press: March 26, 2022
Published online: April 27, 2022
Processing time: 152 Days and 20 Hours
Spontaneous diaphragmatic herniation of the liver is a rare entity. It may mimic pulmonary mass especially in the absence of trauma. Cough is a common side effect of angiotensin converting enzyme (ACE) inhibitors that may cause diaphragmatic rupture due to a sudden increase in trans-diaphragmatic pressure. We present a case of ACE-inhibitor associated spontaneous herniation of the liver mimicking pleural mass.
An 80-year-old woman presented with dry cough for 1 mo and sudden onset of cramping abdominal pain for 1 d. She denied history of trauma, prior surgeries, smoking, alcohol or illicit drug use. She has a history of diabetes and was started on an ACE inhibitor 6 mo ago for the management of hypertension. Examination was remarkable for right upper quadrant tenderness. Lab work-up was unremarkable. Chest X-ray showed a right lower lung opacity suspecting right pleural mass. Chest computed tomography scan ruled out pleural mass, however, revealed herniated right lobe of the liver (3.9 cm × 3.6 cm × 3.4 cm) into the thoracic cavity through the posterolateral diaphragmatic defect. Laparoscopic repair of the diaphragmatic defect was performed and the ACE inhibitor was stopped. Patients’ symptoms had completely resolved on follow-up.
ACE inhibitor-associated cough may cause diaphragmatic liver herniation mimicking pleural mass. Early diagnosis, surgical repair and addressing the triggering factors improve patients’ outcomes.
Core Tip: Diaphragmatic herniation of the liver secondary to angiotensin converting enzyme inhibitors induced cough is uncommon. Cough is a rare cause of diaphragmatic liver herniation and it may be overlooked. This case illustrates the importance of combining clinical presentation with cross-sectional radiological imaging for early diagnosis and surgical repair of diaphragmatic liver herniation and for better patient outcomes.