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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
Diagnosis and Surgical Treatment of Diaphragmatic Rupture Following Blunt Abdominal Traumas
Ahmet Karamercan,Osman Kurukahvecioglu,Yildirim Imren,Tonguc Utku Yilmaz,Mustafa Sare,Bulent Aytac
Surgery Journal , 2012,
Abstract: Diaphragmatic rupture observed in trauma patients with multiple organ injuries is a rare but serious problem. The incidence rate for diaphragmatic rupture is 0.8-5% while mortality rate is between 16.6-33.3%. There are cases in the literature which diaphragmatic rupture was diagnosed years after the trauma. Symptoms related to heart or lung compression due to early or delayed displacement of the abdominal viscera into the thorax or strangulation of abdominal viscera lead the physician to diagnosis. A 75-year old female patient who presented to the emergency room with shortness of breath, abdominal pain, nausea and vomiting complaints had been in a traffic accident 20 days earlier and admitted to the hospital. Abdominal ultrasound, plain radiographs and laboratory tests after the accident had been normal and the patient was discharged after a 24 h follow-up. Patient had signs of intestinal obstruction and abnormal blood gas values and posterior-anterior chest radiograph revealed elevation of the left hemidiaphragm. Thoracic computarized tomography demonstrated elevation of the posterolateral region of the left hemidiaphragm and displacement of the subdiaphragmatic organs within the thorax, up to the level of the carina. The patient had laparotomy under emergency conditions when rupture of the diaphragm was identified and repaired transabdominally. Diaphragmatic ruptures secondary to blunt traumas can be diagnosed with its early or late symptoms. Non-specific symptoms like chest pain, dyspnea, tachypnea, shortness of breath observed in patients should raise suspicion. Early or late deterioration in blood gas analyses following blunt traumas should be assessed carefully. Diagnosis can be rapidly established with direct radiographs, thoracic computarized tomography and magnetic resonance imaging. Treatment of rupture is surgery. Generally the diaphragm is repaired by the transabdominal approach while complicated ruptures can be assessed with a lower thoracic incision. Being extra vigilant following serious blunt traumas is an important factor in establishing the diagnosis.
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
Hepatothorax due to a right diaphragmatic rupture related to duodenal ulcer perforation  [cached]
Se-Jin Baek,Jin Kim,Sung-Ho Lee
World Journal of Gastroenterology , 2012, DOI: 10.3748/wjg.v18.i39.5649
Abstract: Here, we present the case of a 53-year-old man with a hepatothorax due to a right diaphragmatic rupture related to duodenal ulcer perforation. On admission, the patient complained of severe acute abdominal pain, with physical examination findings suspicious for a perforated peptic ulcer. Of note, the patient had no history of other medical conditions or recent trauma, and the initial chest radiography and laboratory findings were not specific. A subsequent abdominal computed tomography revealed intrathoracic displacement of the liver, gallbladder, transverse colon and omentum through a right diaphragmatic defect. The patient then underwent an explorative laparotomy that confirmed duodenal ulcer perforation. A primary repair of the duodenal perforation was performed, and the diaphragmatic defect was repaired using a polytetrafluoroethylene patch after the organs were reduced and the cavity irrigated. This particular case proves interesting as right-sided spontaneous diaphragmatic ruptures are very rare and difficult to diagnose. Additionally, the best treatment for such large diaphragmatic defects is still controversial, especially in cases of intrathoracic or intra-abdominal contamination.
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
Asymptomatic diaphragmatic rupture with retroperitoneal opening as a result of blunt trauma  [cached]
Narci Adnan,Sen Tolga,Koken Resit
Journal of Emergencies, Trauma and Shock , 2010,
Abstract: Blunt traumas of the abdomen and thorax are important clinical problems in pediatric ages. Severity of trauma may not always be compatible with the patients′ clinical situation. A 2-year-old male child was admitted to our emergency clinic as a result of tractor crash accident. Physical examination of the child was normal. The abdominal and thoracic ultrasonography (USG) examination performed in the emergency clinic was normal. In thoracic computed tomography (CT) scan of the patient, there was irregularity of the right diaphragmatic contour that was described as micro perforation-rupture (the free air was just in the perihepatic and retroperitoneal area, which was not passing through the abdomen). The patient was followed-up for 1 week in the hospital with a diagnosis of retroperitoneal diaphragmatic rupture. It is not appropriate to decide the severity of trauma in childhood on the basis of clinical findings. Although severe trauma and sustaining radiological examinations, the patients′ clinical pictures may be surprisingly normal, as in our patient. In such cases, there may not be any clinical symptom. CT scan examination must be preferred to USG for both primary diagnosis and follow-up of these patients. According to the current literature, there is no reported case with retroperitoneal rupture of the diaphragm.
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
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.

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.
Bilateraly Diaphragmatic Traumatic Rupture with Delayed and Liver Herniation of Right Diaphragmatic Rupture  [PDF]
Hatice ?ztürkmen Akay,Refik ülkü
Dicle Medical Journal , 2004,
Abstract: Bilateraly diyafragmatic rupture is a rare pathology. The incidence isregarded 0.8-5%. Here we reported a bilateraly diyafragmatic rupture withdelayed right diyafragmatic liver herniation. We review the literature andwe mentioned the important radiologic findings of the patology withultrasonoghraphy, Computed tomography, and magnetic resonanceimaging.
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