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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
Incarcerated Thoracic Gastric Herniation after Nephrectomy: A Report of Two Cases  [PDF]
Conall Fitzgerald,Orla Mc Cormack,Faisal Awan,Jessie Elliott,Narayanasamy Ravi,John V. Reynolds
Case Reports in Surgery , 2013, DOI: 10.1155/2013/896452
Abstract: Iatrogenic diaphragmatic hernias can occur after abdominal or thoracic surgery. Acute presentation of a diaphragmatic hernia varies depending on the extent and nature of the organ which has herniated. The initial diagnosis can be challenging due to the nonspecific nature of the presenting symptoms. Delay in diagnosis poses a significant risk to the patient, and a rapid deterioration can occur in the context of strangulation. We outline two cases of acute gastric herniation through a defect in the diaphragm after an open and a laparoscopic nephrectomy. Both had characteristic findings on imaging, required emergency, surgery and had a successful outcome. Both cases highlight the potential for late presentation with non-specific symptoms and the necessity for urgent surgical management where gastric perfusion is compromised. 1. Introduction Diaphragmatic hernias are classified as congenital or acquired, congenital hernia types being Bochdalek (95% of cases), Morgagni (2% of cases) and due to diaphragm eventration or central tendon defects. Acquired diaphragmatic hernias are hiatal, traumatic either due to blunt force or penetrating injuries, or iatrogenic. Iatrogenic diaphragmatic hernias are rare complications of thoracic or abdominal surgery, having been described following oesophagectomy, gastrectomy, laparoscopic cholecystectomy, fundoplication, gastric banding, radiofrequency ablation of liver lesions, thoracotomy, splenectomy, and nephrectomy [1–12]. An acute presentation with a strangulated or an obstructed viscus may present a diagnostic dilemma and require urgent resection and repair. We describe herein two cases of delayed diaphragmatic hernia following nephrectomy which resulted in gastric incarceration requiring emergency repair. Both cases highlight late presentations, the potential for late diagnosis, and classical radiological features where high quality computed tomography (CT) is utilized, as well as the need for urgent surgery once the diagnosis is established. 2. Case One A 35-year-old male with polycystic liver and kidney disease, on dialysis, underwent an open bilateral nephrectomy three years prior to a presentation to his local hospital with chest pain, dyspnoea, and a low-grade fever. He was treated for suspected pneumonia, but three days later his condition deteriorated and he progressed rapidly into septic shock with resultant intubation and mechanical ventilation and requirement for inotropic support. A chest radiograph (CXR) at that time (Figure 1) revealed a left-sided pleural effusion with a thoracic air-fluid level and slight
Right-sided diaphragmatic rupture after blunt trauma. An unusual entity
Ramon Vilallonga, Vicente Pastor, Laura Alvarez, Ramon Charco, Manel Armengol, Salvador Navarro
World Journal of Emergency Surgery , 2011, DOI: 10.1186/1749-7922-6-3
Abstract: Traumatic injuries of the diaphragm remain an entity of difficult diagnosis despite having been recognised early in the history of surgery. Sennertus, in 1541, performed an autopsy in one patient who had died from herniation and strangulation of the colon through a diaphragmatic gap secondary to a gunshot wound received seven months earlier [1]. However, these cases remain rare, and difficult to diagnose and care for. This has highlighted some of the aspects related to these lesions, especially when they are caused by blunt trauma and injuries of the right diaphragm [1,2].We report the case of a man of 36 years of age, thrown from a height of 12 meters and was referred to our centre. The patient arrived conscious and oriented, and we began manoeuvring the management of the patient with multiple injuries according to the guidelines of the ATLS (Advanced Trauma Life Support) recommended by the American College of Surgeons. The patient had an unstable pelvic fracture (type B2) with hemodynamic instability and respiratory failure. Patient's Injury Severity Score (ISS) was 38. Pelvis and chest X-rays were performed which confirmed the pelvic fracture and pathological elevation of the right hemidiaphragm was observed (Figure 1). We proceeded to stabilise the pelvic fracture and replace fluids, improving hemodynamic status. The patient continued with respiratory failure. For this reason, a chest tube was placed and Computerised Tomography (CT) was performed (Figure 2), showing a ruptured right hemidiaphragm, including chest drain in the right hepatic lobe and occupation of the lesser sac by blood. The patient underwent surgery, finding a right hemidiaphragm transverse rupture with a hepatothorax and an intrahepatic thoracic tube. We performed the suture of the diaphragm and liver packing, moved the patient to the intensive care unit, and after 48 hours, the liver packing was removed without problems. The patient evolved favourably.Currently, traumatic injuries of the diaph
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.
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 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.
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
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.
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.

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.
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