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Delayed Traumatic Diaphragmatic Hernia presenting with stomach strangulation: suspicion can save lives.
Elsayed & Page
diaphragmatic injury, strangulation
A 54 year old gentleman with history of depression presents with a self inflicted stab wound to his left lower chest in the 9th intercostal space at the anterior axillary line. This resulted in a mild haemothorax which was treated conservatively with a chest drain (Figure 1) and eventually settled as he drained a total of 800ml of blood and was discharged home 2 days later.
Three months later he presents to the emergency department with gradual progressive shortness of breath and a Chest X-ray and consequent CT-scan of the chest (Figure 2a & b) reveal the presence of viscera in his chest.
He is admitted with a plan of transfer to our hospital for elective surgery 3 days later but on the next day becomes acutely unwell with a picture of full blown sepsis. He is transferred on an emergency basis and taken to the operating room where his stomach is found to strangulate and rupture through a diaphragmatic tear. A partial gastrectomy (including the ruptured area) is performed, the stomach pushed back to the abdomen and the tear repaired. He makes an uneventful postoperative recovery and is discharged home 2 weeks later. Clearly the diagnosis of the diaphragmatic injury was missed in the acute settings resulting in herniation and strangulation of the stomach.
Patients complaining of upper abdominal pain and dyspnea with past history of thoraco-abdominal trauma should be evaluated for a missed diaphragmatic injury. A high index of suspicion, physical examination of the chest, and x-ray film are helpful for diagnosis of delayed traumatic diaphragmatic hernias. A CT –scan of the chest may be helpful in the first setting to detect the occult diaphragmatic tear.
1) Hany Elsayed. FRCS Cth. Cardiothoracic department - Liverpool Heart and Chest Hospital- Liverpool- UK
2) Richard Page. FRCS. Cardiothoracic department - Liverpool Heart and Chest Hospital- Liverpool- UK
Cardiothoracic Department - Liverpool Heart and Chest hospital- - L14 3PE- Liverpool- UK
Copyright Priory Lodge Education Limited 2010
First Published September 2010