School ager with right lower quadrant pain, fever, and elevated white blood cell count

Upper GI exam of congenital diaphragmatic hernia / Bochdalek hernia — AXR AP (above) is remarkable for a paucity of bowel gas in the abdomen. CXR PA (below left) obtained at the same time to rule out right lower lobe pneumonia as a cause of referred right lower quadrant pain shows dense opacity throughout the left hemithorax. CXR PA (below right) obtained during an upper GI and small bowel follow through exam shows a large amount of small bowel in the left hemithorax.

The diagnosis was delayed presentation of a left congenital diaphragmatic hernia. In the operating room the patient was also found to have acute appendicitis.