|Year : 2016 | Volume
| Issue : 1 | Page : 23-26
Diaphragmatic rupture presenting with strangulated hernia: Report of two cases
Isaac Assam Udo, Kingsley U Umeh
Department of Surgery, University of Uyo Teaching Hospital, Uyo, Akwa Ibom, Nigeria
|Date of Web Publication||8-Dec-2016|
Dr. Isaac Assam Udo
Department of Surgery, University of Uyo Teaching Hospital, Uyo, Akwa Ibom
Source of Support: None, Conflict of Interest: None
Traumatic rupture of the diaphragm can complicate blunt abdominal trauma. It is rare in our practice, and its diagnosis may be delayed if the index of suspicion is low among emergency room physicians. Imaging studies can easily confirm the diagnosis of diaphragmatic rupture. Herniation of organs and viscera through the diaphragmatic defect occurs commonly, and same may obstruct or strangulate and worsen the outcome. We present two adults with complaints of severe acute abdominal pain and a history of high-speed vehicular trauma whose definitive diagnoses were delayed. The presence of air-fluid levels in the left hemithorax on a chest radiogram and a history of blunt abdominal injury made us arrive at the diagnosis of intestinal obstruction secondary to traumatic diaphragmatic hernia.
Keywords: Diaphragmatic rupture, herniation of viscera, strangulation
|How to cite this article:|
Udo IA, Umeh KU. Diaphragmatic rupture presenting with strangulated hernia: Report of two cases. Afr J Trauma 2016;5:23-6
| Introduction|| |
Post-traumatic diaphragmatic hernias are very rare events in our local practice, but it would appear the incidence is rising. High speed vehicular trauma is the primary cause; poor road and vehicle maintenance are contributory.
Retraining the ER staff on the mechanisms, diagnosis and management of chest trauma is vital to early suspicion, detection and treatment of these injuries. The early use of supplemental imaging in traumatized patients reduces the chance of missed injury and prevents associated morbidity and mortality.
Established cases of traumatic diaphragmatic rupture with visceral herniation require urgent surgery to repair the rupture and prevent strangulation while strangulated intestines will require resection. Delays in diagnosis and treatment heighten mortality from strangulation and sepsis.
| Case Reports|| |
A 30-year-old male presented in the emergency room (ER) with a 3-day history of severe, acute, colicky abdominal pain worse in the left upper abdomen with no known precipitating or relieving factors. He vomited five times before and while being transported to hospital, and he was unable to pass feces or flatus over the duration of symptoms. He volunteered a history of recurrent epigastric pain in the past 3 years for which he received treatment for peptic ulcer disease with no significant relief of his symptoms. He also volunteered being involved in a vehicular accident 3 years previously and experienced transient abdominal pain necessitating overnight admission and observation in an ER and was discharged the next morning without any imaging studies done. He had no respiratory symptoms after the accident or with the current illness.
He was acutely ill, pale, febrile (T = 37.9°C), and dehydrated with a grossly distended and tender abdomen with resonance and a positive fluid thrill. His respiratory rate was 24 breaths/min. The bowel was silent. His packed cell volume was 40%, and the electrolytes were within normal range. A chest radiogram taken to include the upper abdomen showed air-fluid levels in the left hemithorax with similar features in the abdomen [Figure 1]. A definitive clinical diagnosis of intestinal obstruction secondary to diaphragmatic hernia was made, and patient resuscitated and scheduled for laparotomy.
|Figure 1: Chest radiogram showing air-fluid levels in the left hemithorax and left upper abdomen|
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Intraoperatively, we encountered markedly dilated loops of small and large bowel containing large volume fluid and a contracted and empty descending colon. After decompressing the dilated bowel, the point of herniation of the splenic flexure of colon was identified in the left hemidiaphragm [Figure 2]. A 4 cm incision was placed on the left diaphragm [Figure 3] and a finger inserted to free gangrenous bowel and omentum from the chest cavity and the diaphragm closed in two layers. Resection of the strangulated bowel with primary anastomosis was done. A thoracostomy tube was inserted into the left pleural cavity. The postoperative period was unremarkable; he made good progress, and a repeat chest radiogram was normal. He was discharged on the 12th day postoperatively.
|Figure 2: Point of herniation of intestine in the ruptured left hemidiaphragm|
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|Figure 3: Incision on the diaphragm to free gangrenous loop of intestine. Omentum is also gangrenous and yet to be freed|
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A 56-year-old female presented in the ER with a history of progressively severe abdominal pain and difficulty in breathing over 48 h. She volunteered a history of vehicular trauma 12 days before presentation where she sustained injuries to her left trunk. She had not passed feces or flatus for 5 days and vomited twice. She received emergency attention in a secondary facility immediately after the incident and was discharged after 48 h.
She was ill-looking with healed bruises on her face and trunk. Her respiratory rate was 27 breaths/min and pulse rate was 130/min. Her abdomen was distended and tender, no mass was palpated, and bowel sounds were absent. Thoracocentesis yielded hemorrhagic fluid. Abdominal ultrasound scan showed fluid collection and a chest X-ray bowel loops in the left chest.
The findings at laparotomy were two tears in the diaphragm; one in the left containing a loop of strangulated ileum and another in the central tendon measuring 10 cm long through which part of the heart herniated into the peritoneal cavity [Figure 4]. The strangulated bowel loop was freed with primary resection and anastomosis done. Both lacerations in the diaphragm were repaired in two layers. She had thoracostomy tube inserted and received intensive care in the immediate postoperative period.
|Figure 4: Large laceration in the central tendon of the diaphragm through which the heart partly herniated into the abdominal cavity|
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| Discussion|| |
Posttraumatic diaphragmatic rupture in adults is a rare event in our practice; it is reported to be even rarer in pediatric surgery practice. Traumatic rupture of the diaphragm is a known consequence of blunt abdominal trauma following road traffic accident or falls from height and predominantly affects young male adults.
The left hemidiaphragm is disposed to rupture in more than 70% of cases,, in particular its posterolateral aspect because of its origins from the weak pleuroperitoneal membrane. This anatomical site was very typical in both patients. The second patient had a very large rupture of the central tendon of the diaphragm as well. Incidental diaphragmatic ruptures in unsuspected patients have been reported at laparotomy or laparoscopy. The right hemidiaphragm ruptures less frequently because it is protected by the bulk of the liver, but where it does occur, the incidence of viscera herniating is low.,
Failure to make an early diagnosis of diaphragmatic rupture is not unusual and may arise from delayed detection of injury, delayed injury, or absence of symptoms. Delayed detection of diaphragmatic rupture is common where the incident officers at the ER are inexperienced, rarely encounter cases of diaphragmatic rupture or are not trained to manage serious trauma. In such scenario, early suspicion of such severe injuries and investigations to rule out same is lacking. This resulted in the first patient being undiagnosed despite seeking medical attention early after the trauma and subsequently presenting with symptoms of partial intestinal obstruction for over 3 years and was managed instead for peptic ulcer disease despite the failure of symptoms to resolve.
Features suggesting diaphragmatic rupture include auscultating audible bowel sounds in the chest, absence of breath sounds in the affected chest, difficulty in breathing and the finding of bowel in the thoracic cavity, elevated hemidiaphragm, or visualization of a nasogastric tube in the thoracic cavity on a chest radiogram. The diagnosis of rupture in the first case was delayed most likely because the size of the tear was very small, so herniation of intestine might have been delayed as he remained free of symptoms during the overnight observation in the ER. He also had no imaging studies done after the initial incident or during the period he complained of persisting epigastric pain. These observations are important and call for a high index of suspicion of other injuries, including diaphragmatic rupture, in patients presenting with blunt abdominal injury among ER physicians in our practice.
Herniation of intra-abdominal contents into the chest following traumatic diaphragmatic injury is rare and presents with diagnostic and therapeutic difficulties. Where the rent in the diaphragm is wide herniation may occur immediately after the incident but is delayed with small rents; the delayed type may remain silent for years and present with obstruction and strangulation as in the index case. Organs that can herniate include the stomach, intestines, omentum, and liver. In the second patient, we observed that thoracic structures as the heart can also herniated into the abdominal cavity. The omentum was the primary organ that herniated and pulled on a loop of the mobile transverse colon through the narrow defect leading to obstruction and strangulation.
Primary resection and anastomosis of the large intestine are routine in our practice among hemodynamically stable emergent patients, employing a single-layer closure technique devoid of excessive tension. Adopting this approach has significantly reduced the number of patients with benign conditions undergoing multistaged abdominal procedures in our surgical unit. The great disparity in luminal diameter between the proximal and distal bowel lumen in the index patient was a recognized risk for anastomotic failure which called for utmost technical care in executing the anastomosis.
An important lesson from the index case was the lack of a high index of suspicion of diaphragmatic rupture and obstructed or strangulated intestine in a ruptured diaphragm among the ER physicians in our secondary care hospitals and a need for training and retraining to recognize the clinical and radiological features of thoracic injuries. With the increased incidence of high impact trauma in our society, there is a strong need to imagine a wider possibility of injuries in blunt trauma.
| Conclusion|| |
Strangulated hernias from diaphragmatic ruptures are rare. A high index of suspicion with logical use of imaging modalities can easily suggest the diagnosis. Delays in treatment worsen the morbidity and mortality.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]