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Delayed Presentation of Traumatic Diaphragmatic Rupture with Herniation of the Left Kidney and Bowel Loops  [PDF]
Amiya Kumar Dwari,Abhijit Mandal,Sibes Kumar Das,Sudhansu Sarkar
Case Reports in Pulmonology , 2013, DOI: 10.1155/2013/814632
Abstract: Rupture of the diaphragm mostly occurs following major trauma. We report a case of delayed presentation of traumatic diaphragmatic hernia on the left side in a 44-year-old male who presented two weeks after a minor blunt trauma. Left kidney and intestinals coils were found to herniate through the diaphragmatic tear. This case demonstrates the importance of considering the diagnosis in all cases of blunt trauma of the trunk. It also illustrates the rare possibility of herniation of kidney through the diaphragmatic tear. 1. Introduction Traumatic diaphragmatic hernias (DH) represents only small percentage of all diaphragmatic hernias but it is no longer an uncommon entity. Injury is mostly caused by severe blunt or penetrating trauma [1]. DH may be recognized during the period of hospitalization immediately following trauma. If the diaphragmatic injury is not recognized during the immediate posttraumatic period, the patient may recover and remain symptom free or present either with chronic thoracoabdominal symptoms or with acute emergency due to intestinal strangulation [2]. During the delayed presentation with chronic thoracoabdominal symptoms, the trauma responsible for the injury is often forgotten and the diagnosis is not suspected. A careful history, physical examination, and awareness of the possibility are the prerequisite for timely diagnosis. Abdominal organs that commonly herniate are stomach, spleen, liver, mesentery, and small and large bowels. Kidney is rarely found to herniate through the diaphragmatic tear [3]. The case is unique due to occurrence of the DH with minor trauma, its delayed presentation, and herniation of the left kidney into the thorax. 2. Case Report A 44-year-old male patient was kicked in his left lower chest and upper abdomen by a neighbour during a family quarrel. Considering it to be a minor trauma, he continued his daily activities for the next two weeks. He presented to pulmonary medicine outpatient department with left sided dull aching chest pain and nonproductive cough for ten days. There was no history of abdominal pain or haematuria. On examination, he was afebrile but dyspneic (MMRC grade 2) with respiratory rate of 22 breaths/min, oxygen saturation of 96% with room air, pulse rate of 90/min, and blood pressure of 138/84?mm of Hg. On examination of the chest, there was dull note over left infraclavicular area and bowel sounds were audible over the left side of the chest. Examination of other systems was within normal limits. His chest X-ray PA view revealed a heterogeneous opacity in left lower zone but no
Delayed diagnosis of a right-sided traumatic diaphragmatic rupture  [cached]
Alexandr Ku?era,Michal Rygl,Ji?í ?najdauf,Lucie Kavalcová
Clinics and Practice , 2012, DOI: 10.4081/cp.2012.e3
Abstract: Right-sided traumatic diaphragmatic rupture in childhood is a very rare injury. Diaphragmatic rupture often manifests itself later, after an organ progressively herniates into the pleural cavity. When the patient is tubed, the ventilation pressure does not allow herniation of an organ, which occurs when the patient is ex-tubed. We present a patient with a delayed diagnose of right sided diaphragmatic rupture with a complicated post-operation state.
Laparoscopic Treatment of a Rare Right Diaphragmatic Rupture with Small Bowel Herniation after Blunt Thoracic Trauma  [PDF]
H. Hoffmann,D. Oertli,O. Heizmann
Minimally Invasive Surgery , 2010, DOI: 10.1155/2010/109062
Abstract: Blunt traumatic diaphragmatic rupture (BTDR) is a life-threatening condition with an incidence from 0,8%–1,6% in blunt trauma, mostly located on the left side. The main prognostic factors are severe side injuries and the delay of diagnosis. We present a rare case of a 68-year-old female, with an isolated right diaphragm rupture. The diagnosis was done with a delay of 4 days by thoracic radiographs, which showed a herniation of small bowel into the right thoracic cavity. A reposition of the small bowel and a closure of the diaphragmatic defect by running suture were carried out laparoscopicly. Although large prospective studies concerning the outcome of laparoscopic approach to right BTDR are still missing, we could show, that laparoscopy can be performed safely in right traumatic diaphragm rupture. 1. Introduction Blunt traumatic diaphragmatic rupture (BTDR) is a life-threatening condition with an incidence of 0.8%–1.6% in blunt trauma [1–3]. The closure of the diaphragm rupture must be performed immediately. The diagnosis often happens to be late due to the absence of typical symptoms or other major injuries dominating the clinical aspect [4]. An isolated BTDR is rare and thus might be followed by a period of weeks or months not revealing any symptoms [2, 5]. Most BTDR are located on the left side in the musculotendinous intersection [1, 3, 4]. Right BTDR are rarely described and less frequent [6]. Herniation of colon, small bowel, or liver may occur and result in ileus, necrosis, and perforation [4, 7]. 2. Narrative We present a rare case of a 68-year-old female hospitalized in the neurological department due to Parkinson disease. She fell onto a chair hitting her right hemithorax. Initially, subjective symptoms have been missing. The examination showed a slightly reduced breath without any signs of pneumothorax or dyspnea, a decent pressure pain and a bruise. 4 days after trauma, she developed a progressive pulmonal decompensation with desaturation. Additionally, there have been signs of ileus. The chest radiograph displayed a herniation of bowel into the right hemithorax with consecutive ileus signs (Figure 1). Figure 1: Chest radiograph shows bowel herniation into right hemithorax. We performed a laparoscopic approach and found a ?cm rupture of the right diaphragm with herniation of 1 meter small bowel. The bowel appeared vital after reposition. The transdiaphragmatic thoracoscopy displayed a collapsed lung and a dislocated rib fracture (Figure 2). After irrigation of the thoracic cavity we made a direct laparoscopic strainless running suture with
A review on delayed presentation of diaphragmatic rupture
Farhan Rashid, Mallicka M Chakrabarty, Rajeev Singh, Syed Y Iftikhar
World Journal of Emergency Surgery , 2009, DOI: 10.1186/1749-7922-4-32
Abstract: A Pubmed search was conducted using the terms "delayed presentation of post traumatic diaphragmatic rupture" and "delayed diaphragmatic rupture". Although quite a few articles were cited, the details of presentation, investigations and treatment discussed in each of these were not identical, accounting for the variation in the data presented below.Late presentation of diaphragmatic rupture is often a result of herniation of abdominal contents into the thorax[1]. Sudden increase in the intra abdominal pressure may cause a diaphragmatic tear and visceral herniation[2]. The incidence of diaphragmatic ruptures after thoraco-abdominal traumas is 0.8–5% [3] and up to 30% diaphragmatic hernias present late[4]. Diaphragmatic, lumbar and extra-thoracic hernias are well described complications of blunt trauma [5]. Incorrect interpretation of the x ray or only intermittent hernial symptoms are frequent reasons for incorrect diagnosis[6].Diaphragmatic rupture with abdominal organ herniation was first described by Sennertus in 1541[7,8]. Diaphragmatic injury is a recognised consequence of high velocity blunt and penetrating trauma to the abdomen and chest rather than from a trivial fall[8]. These patients usually have multi system injuries because of the large force required to rupture the diaphragm[9].Blunt trauma to the abdomen increases the transdiaphragmatic pressure gradient between the abdominal compartment and the thorax[10]. This causes shearing of a stretched membrane and avulsion of the diaphragm from its points of attachments due to sudden increase in intra abdominal pressure, transmitted through the viscera[11]. Delay in presentation of a diaphragmatic hernia could be explained by various different hypotheses. Delayed rupture of a devitalised diaphragmatic muscle may occur several days after the initial injury [8]. This is best exemplified in the case report of bilateral diaphragmatic rupture [12], where the left diaphragmatic rupture was identified 24 hours after th
Delayed presentation of blunt traumatic diaphragmatic hernia: A case report
AT Kidmas, D Iya, ES Isamade, E Ekedigwe
Nigerian Journal of Surgical Research , 2005,
Abstract: Blunt traumatic diaphragmatic rupture is an uncommon but severe problem that is usually seen in poly-traumatized patients. Diagnosis is often difficult resulting in delayed presentation and increased morbidity. We report a case of blunt traumatic diaphragmatic hernia in a 39-year-old man presenting 10 years after the initial abdomino-thoracic injury sustained in a road traffic accident. He had herniation of the spleen and stomach. Through a left thoracotomy, the herniated organs were reduced and diaphragmatic defect closed with interrupted nylon sutures. A high index of suspicion would minimize the morbidity and mortality associated with delayed diagnosis.
Strangulated Tension Viscerothorax with Gangrene of the Stomach in Missed Traumatic Diaphragmatic Rupture  [PDF]
Uvie Onakpoya,Akinwumi Ogunrombi,Anthony Adenekan,William Akerele
ISRN Surgery , 2011, DOI: 10.5402/2011/458390
Abstract: Acquired diaphragmatic hernias are usually posttraumatic in occurrence. In patients who have blunt trauma and associated diaphragmatic hernia, the diagnosis may be missed or delayed, often leading to poor treatment outcomes. We present a rare occurrence of tension viscerothorax due to missed traumatic diaphragmatic rupture in a 25-year-old woman whose condition was complicated by gangrene and perforation of the fundus as well as questionable viability of the anterior wall of the body of the stomach. The patient had a successful emergency transabdominal suture plication of the diaphragm and gastroplasty and has remained symptomless 3 months postoperatively. 1. Introduction Acquired diaphragmatic hernias are usually posttraumatic in occurrence. They occur following motor vehicular accidents, falls, and stabs or after laparoscopic upper abdominal surgeries [1]. Though penetrating chest and abdominal injuries have higher chances of causing diaphragmatic hernias, it is well known that blunt trauma is associated with the condition. The diagnosis of a diaphragmatic rent is often made in patients who suffer penetrating abdominal injuries because they have higher incidences of operative intervention and as such, the diagnosis is usually made intraoperatively. However, in patients who have diaphragmatic hernia due to blunt trauma, the diagnosis may be missed or delayed, leading to poor outcomes [2, 3]. Tension viscerothorax occurring as a result of a traumatic diaphragmatic hernia is very rare [4]. We present a case of tension viscerothorax occurring in patient with missed traumatic diaphragmatic rupture whose condition was complicated by gangrene and perforation of the fundus and questionable viability of the anterior wall of the body of the stomach. 2. Case Report A 25-year-old lady was referred from a medical facility in 2010 where she had previously been managed for 8 weeks for a left shoulder avulsion injury and blunt chest trauma sustained during a motor vehicular accident. She had a successful skin grafting and was considered for discharge home a day before she was referred to us when she suddenly developed difficulty with breathing, dull aching central chest pain, and palpitations. She was referred on intravenous dopamine support due to a cardiovascular collapse and was immediately admitted into the intensive care unit (ICU) of the Obafemi Awolowo University Teaching Hospital. Examination revealed a profusely sweaty young woman who was pale, dehydrated, and in severe respiratory distress (respiratory rate, 58 cycles/min) despite being on intranasal oxygen
Diaphragmatic rupture with right colon and small intestine herniation after blunt trauma: a case report
Mirko Muroni, Giuseppe Provenza, Stefano Conte, Andrea Sagnotta, Niccolò Petrucciani, Ivan Gentili, Tatiana Di Cesare, Andrea Kazemi, Luigi Masoni, Vincenzo Ziparo
Journal of Medical Case Reports , 2010, DOI: 10.1186/1752-1947-4-289
Abstract: We report a case of a 59-year-old Italian man hospitalized for abdominal pain and vomiting. His medical history included a blunt trauma seven years previously. A chest X-ray showed right diaphragm elevation, and computed tomography revealed that the greater omentum, a portion of the colon and the small intestine had been transposed in the hemithorax through a diaphragm rupture. The patient underwent laparotomy, at which time the colon and small intestine were reduced back into the abdomen and the diaphragm was repaired.This was a unusual case of traumatic right-sided diaphragmatic hernia. Diaphragmatic ruptures may be revealed many years after the initial trauma. The suspicion of diaphragmatic rupture in a patient with multiple traumas contributes to early diagnosis. Surgical repair remains the only curative treatment for diaphragmatic hernias. Prosthetic patches may be a good solution when the diaphragmatic defect is severe and too large for primary closure, whereas primary repair remains the gold standard for the closure of small to moderate sized diaphragmatic defects.Traumatic rupture of the diaphragm is an uncommon condition. It occurs in 0.8 to 5% of patients admitted to hospital with thoracoabdominal trauma. The etiologic factors are blunt trauma (for example, in motor vehicle accidents) and penetrating trauma [1]. The organs most commonly involved in right-sided diaphragmatic hernias are the colon, omentum, small intestines and liver.Chest radiography and computerized tomography is the most effective method for diagnosis of traumatic diaphragmatic rupture [2]. Treatment is surgical, with reduction of the viscera and simple repair of the diaphragm with non-absorbable suture.A 59-year-old Italian man presented with abdominal pain localized in the right upper quadrant, constipation and vomiting for longer than one week. The patient had inconstant symptoms including shortness of breath and dyspnea. His medical history included right-sided rib fractures in a moto
Isolated Blunt Traumatic Diaphragmatic Rupture in a Case of Situs Inversus  [PDF]
Raiees Ahmad, Malik Suhail, Alfer Nafae, Qayoom Khan, Pervaze Salam, Shahnawaz Bashir, Yawar Nisar
Surgical Science (SS) , 2015, DOI: 10.4236/ss.2015.63021
Abstract:

Situs inversus, a very rare congenital anomaly of reversal site of thoracic and abdominal organs, can be very problematic to surgeon while dealing with a case of trauma in emergency. Surgical procedures are considered difficult, complex and more challenging in patients with this condition due to the anatomical difference and position of organs. We came across an interesting and very rare case of isolated blunt traumatic diaphragmatic injury in a case of situs inversus. Traumatic injuries of the diaphragm are uncommon and isolated blunt traumatic injuries of diaphragm are very rare. Our case is very unique of its kind of situs inversus with isolated right sided diaphragmatic rupture in a 60-year-old male patient presenting 4 hours after blunt trauma to chest and abdomen.

Traumatic Diaphragmatic Ruptures: A retrospective study of 35 cases
Hasd?raz, L.,Kahraman, A.,O?uzkaya, F.
Erciyes Medical Journal , 2006,
Abstract: Purpose: Traumatic rupture of the diaphragm is caused by blunt or penetrating trauma. Early diagnosis is difficult, and complications such as visceral herniation may arise. The aim of this study was to evaluate our diagnostic and therapeutic approaches for traumatic diaphragmatic ruptures in the last ten-year period.Patients and Methods: Thirty-five patients who were diagnosed with traumatic diaphragmatic ruptures in the last ten-year period were retrospectively reviewed. Of the patients, 24 were male and 11 female. The mean age of the patients was 30 yrs (range 14–66 yrs). The mechanism of injuries, associated injuries, diagnostic and surgical approaches, and the morbidity and mortality rate were evaluated.Results: Blunt injuries were common (71.4%). Chest x-ray, thorax CT, and video assisted thoracoscopic surgery were used for the diagnosis with a diagnostic rate of 22.8%, 22.7% and 58.8%, respectively. Interrupted and running techniques with nonabsorbable sutures were used to repair the diaphragma via thoracotomy in all patients. Pleural empyema was seen in two patients. The mortality rate was 2.9%.Conclusion: Video assisted thoracoscopy is a valuable diagnostic procedure in suspected traumatic diaphragmatic rupture with radio diagnostic procedures. Thoracotomy and primary repairing may be adequate, especially in the late period, for traumatic diaphragmatic ruptures.
Post-traumatic diaphragmatic herniation of the liver, examined by positron emission tomography: case report
Katsutoshi Sato, Kazumasa Orihashi, Yoshiharu Hamanaka, Norimasa Mitsui, Shinji Hirai, Naru Chatani, Takashi Nishisaka
World Journal of Emergency Surgery , 2011, DOI: 10.1186/1749-7922-6-30
Abstract: Diaphragmatic herniation of the liver following blunt trauma may develop long after the initial trauma and remain clinically silent. Unless a large portion of liver and/or other abdominal organs are herniated, it is often difficult to distinguish diaphragmatic herniation of the liver from an intrathoracic tumor [1]. Positron emission tomography (PET) imaging using fluorodeoxyglucose (FDG) labeled with the positron-emitter fluorine-18 provides useful information allowing differentiation of benign lesions from malignant ones. However, FDG is a nonspecific marker of malignancy, and uptake may be seen at sites of active inflammation [2], and also from normal metabolically active tissues, such as the liver [3,4]. We report a case of small diaphragmatic herniation of the liver with diagnostic PET and histological findings. We believe this is the first reported case in the literature of PET findings of herniated liver.A 68-year-old woman was involved in an automobile accident and was transferred to the emergency department at the Hiroshima Prefectural Hospital. Computed tomography (CT) on admission demonstrated traumatic aortic injury, multiple rib fractures, and bilateral hemo-pneumothoraces as well as a spiculated mass, 2 cm diameter with pleural indentation in segment 6 of the right lung. She underwent emergent repair of the descending aorta and right pleural drainage. On the fourth post-operative day, bloody drainage from the right chest suddenly increased in volume. The patient was taken back to the operating room and at right thoracotomy, a bleeding point was found on the surface of the diaphragm. Hemostasis was established by using polypropylene suture.Four months later, the size of lung mass was unchanged, and PET showed little FDG uptake. Because malignancy was suspected and her general condition improved, she underwent surgical resection of the tumor. After meticulous dissection, the right lower lobe was partially resected, but systematic lobectomy and radical ly
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