Delayed presentation of a traumatic diaphragmatic rupture with intrapericardial herniation

Thoracic and abdominal blunt traumas are the major causes of diaphragmatic rupture. These ruptures may be recognized at the time of the initial trauma, but are diagnosed months or even years later during the workup for related symptoms. We present herein a patient who suffered from abdominal pain and dyspnea years after a motor vehicle accident. A chest computed tomography (CT) demonstrated diaphragmatic rupture with intrapericardial herniation of intraabdominal organs. Exploratory laparotomy confirmed the diagnosis. In this report, we describe our management of this unusual diaphragmatic rupture.     

Laparoscopic management of a late-diagnosed major diaphragmatic rupture

A 20-year-old male patient was admitted to our emergency ward because of acute respiratory insufficiency following gastroscopy 2 years after a car accident. The chest radiograph showed migration of the stomach into the left hemithorax. A large diaphragmatic hernia was diagnosed and repaired laparoscopically using slowly resorbable sutures and patches. Diaphragmatic rupture secondary to blunt thoracic or abdominal trauma is a rare injury, whose diagnosis may be delayed. The majority of these defects are diagnosed during laparotomy performed for other major abdominal lesions. If diaphragmatic rupture is suspected, and no lesion of a parenchymatous organ has been diagnosed, there is a role for diagnostic laparoscopy. In the absence of other abdominal injuries, diaphragmatic rupture can be repaired by minimal-access surgery.     

Management of Delayed Presentation of a Right-Side Traumatic Diaphragmatic Rupture

Background  

Right-side diaphragmatic rupture is an unusual condition after blunt trauma. The diagnosis may be missed during the early period of trauma and may lead to progressive herniation of intraabdominal contents into the thorax. In this study, we aimed to evaluate the diagnosis and treatment options for the late diagnosis of cases of right-side traumatic diaphragmatic rupture.     

Impact of deferred treatment of blunt diaphragmatic rupture: a 15-year experience in six trauma centers in Quebec

BACKGROUND: The purpose of this study was to show that blunt diaphragmatic rupture does not require immediate emergency operation in the absence of other indications. METHODS: We reviewed all patients with blunt diaphragmatic rupture admitted within 24 hours of injury to one of six university trauma centers providing trauma care for the province of Quebec from April 1, 1984, to March 31, 1999. Multivariate analysis of demographic profiles, severity indices, indications for operation, and preoperative delays was performed. RESULTS: There were 160 patients (91 men and 69 women) with blunt diaphragmatic rupture. Mean age was 40.1 +/- 16.2 years. Mean Injury Severity Score was 26.9 +/- 11.5 and mortality was 14.4%. Patients undergoing emergency surgery for indications other than diaphragmatic rupture had a significantly higher Injury Severity Score than those undergoing surgery for repair of diaphragmatic rupture alone (34.7 +/- 10.7 vs. 22.0 +/- 9.0, p < 0.001). In patients undergoing surgery for diaphragmatic rupture alone, delay before repair of the diaphragmatic hernia did not lead to an increased mortality compared with patients undergoing immediate surgery (3.4% vs. 5.0%, p = NS). CONCLUSION: Blunt diaphragmatic rupture in the absence of other surgical injuries carries low mortality. Operative repair of diaphragmatic rupture can be deferred without appreciable increased mortality if no other indication mandates immediate surgery.     

Delayed and fortuitous diagnosis of right diaphragmatic rupture during preoperative evaluation

Although diaphragmatic rupture occurs after violent blunt trauma, its diagnosis is often delayed. The intra-thoracic displacement of abdominal organs through diaphragmatic rupture may lead to early or delayed complications because of compression of heart and lungs or strangulation of the abdominal viscera. A 49-year-old woman was scheduled to undergo elective lumbar disc surgery in prone position. The preoperative chest radiograph revealed an abnormally elevated right hemi diaphragm with loops of colon filling the right costophrenic angle. The CT-scan confirmed right chronic diaphragmatic rupture with colon and liver herniations. Fifteen months previously, this woman had been involved in a traffic accident, with blunt right trauma resulting in right pelvic fractures. Perianaesthetic course increase the pre-existing mechanical risk of complications of chronic diaphragmatic rupture. Primary repair of right chronic diaphragmatic rupture through thoracotomy must be recommended. When another surgery must be done in emergency, the feasibility of regional anaesthesia should be considered.     

Left-sided perinephric hematoma associated with rupture of the left hemidiaphragm: a marker for renal artery injury

Renal artery injury is an uncommon consequence of blunt abdominal trauma and probably is often missed. We recently saw three patients with rupture of the left hemidiaphragm associated with renal artery injury. The finding of a perinephric hematoma in a multiply injured patient with an ipsilateral diaphragmatic rupture prompted evaluation of the renal artery. With massive injury, the kidney may be displaced superiorly when the diaphragm ruptures, producing injury to the ipsilateral renal artery. This association has not been emphasized in the literature. The finding of a perinephric hematoma on the left should prompt full evaluation of the renal arteries if seen in association with diaphragmatic rupture.     

Delayed diagnosis of traumatic diaphragmatic rupture with herniation of the liver: a case report

Diaphragmatic rupture is a potentially life-threatening clinical situation. It occurs as a result of high-velocity blunt or penetrating injury to the abdomen and thorax. Acute traumatic rupture of the diaphragm may go undetected, and there is often a delay between the injury and diagnosis. Right-sided rupture is less common due to hepatic protection and increased strength of the right hemidiaphragm. We report the case of a 28-year-old man who was admitted with breathlessness to our hospital, 72 hours after trauma. Since clinical signs and symptoms were nonspecific, helical computed tomography was done, which revealed diaphragmatic rupture with hepatothorax. Emergency thoracotomy was done to repair diaphragmatic rent. The postoperative period was uneventful, and the patient was discharged three weeks later.     

Undiagnosed rupture of right hemidiaphragm--hepatothorax: a case report

A case of late diagnosis of right diaphragmatic rupture due to blunt trauma is presented. Traumatic diaphragmatic rupture is an uncommon but severe problem in a patient with multiple injuries. One third of left-sided ruptures and half of right-sided ruptures have been undetected for several days. Traumatic diaphragmatic rupture should be suspected on the basis of an abnormal chest X-ray in patients with multiple injuries. Imaging studies like computed tomography, scan and magnetic resonance imaging can be helpful for differential diagnosis. Right-sided injuries occur more commonly than previously thought and often require thoracotomy.     

Blunt diaphragmatic rupture diagnosed by laparoscopy: report of a case.

Diagnostic laparoscopy provided a minimally invasive and definitive means of diagnosing right-sided diaphragmatic rupture in this patient. The authors recommend laparoscopy as a diagnostic consideration for the patient with suspected traumatic diaphragmatic rupture who presents a difficult diagnostic challenge.     

Anesthetic management of a patient with congenital diaphragmatic eventration

Congenital diaphragmatic eventration is uncommon in adults and is caused by paralysis, aplasia or atrophy of the muscular fibers of the diaphragm. It may cause severe dyspnea, orthopnea and hypoxia in adult patients. Most symptomatic patients may be managed efficiently without the need for surgical correction, although any event that leads to an increase in intra-abdominal pressure puts them at the risk of spontaneous diaphragmatic rupture. This case report presents the successful anesthetic management of an adult female with congenital diaphragmatic eventration undergoing diagnostic laparoscopy and hysteroscopy using a total intravenous anesthesia technique. Essential steps to prevent any rise in intrathoracic and intra-abdominal pressures along with care to minimize intragastric volume were taken.     

Magnetic resonance imaging in traumatic diaphragmatic rupture: case reports.

Acute traumatic diaphragmatic rupture is usually diagnosed by plain chest x-ray studies or at laparotomy. On occasion, ancillary diagnostic procedures such as computed tomography (CT) and fluoroscopy are necessary for diagnosis. Suspected acute traumatic diaphragmatic rupture was definitively diagnosed by magnetic resonance (MR) imaging in two patients. In another three patients, MR imaging was used to rule out diaphragmatic rupture. Magnetic resonance imaging may be the ancillary diagnostic procedure of choice following equivocal chest radiographs.     

Late post-traumatic diaphragmatic hernia: unusual cause of colonic occlusion

Traumatic diaphragmatic rupture is not an uncommon problem, particularly in the last few years because of the increasing number of road accidents, improved diagnostic techniques and resuscitation techniques after serious traumas. In a certain number of cases, post-traumatic diaphragmatic hernias may become clinically manifest only months or years after thoracic or abdominal trauma and are still a challenge to surgeons because of the vague clinical symptoms and the diagnostic difficulties involved. The Authors report a case of acute colon occlusion due to diaphragmatic hernia 24 months after thoraco-abdominal trauma. None of the radiological or endoscopic examinations demonstrated the presence of diaphragmatic hernia. Laparoscopy showed a diaphragmatic rupture with incarceration of the left colonic segment. The laparoscopic procedure was converted for technical reasons and the diaphragmatic defect was closed with a primary suture.     

Clinical effects of laparotomy with perioperative continuous peritoneal lavage and postoperative hemofiltration in patients with severe acute pancreatitis

Diaphragmatic rupture is a life-threatening condition. Diaphragmatic injuries are quite uncommon and often result from either blunt or penetrating trauma. Diaphragmatic ruptures are usually associated with abdominal trauma however, it can occur in isolation. Acute traumatic rupture of the diaphragm may go unnoticed and there is often a delay between the injury and the diagnosis. A comprehensive literature search was performed using the terms "delayed presentation of post traumatic diaphragmatic rupture" and "delayed diaphragmatic rupture". The diagnostic and management challenges encountered are discussed, together with strategies for dealing with them. We have focussed on mechanism of injury, duration, presentation and site of injury, visceral herniation, investigations and different approaches for repair. We intend to stress on the importance of delay in presentation of diaphragmatic rupture and to provide a review on the available investigations and treatment methods. The enclosed case report also emphasizes on the delayed presentation, diagnostic challenges and the advantages of laparoscopic repair of delayed diaphragmatic rupture.     

Late Presentation of a Traumatic Rupture of the Diaphragm with Gastric Volvulus in a Child: Report of a Case

Rupture of the diaphragm following blunt trauma is rare in children. A late presentation of a left diaphragmatic rupture with gastric volvulus is also highly exceptional. The authors report the case of a 5-year-old boy with a left diaphragmatic rupture, who presented with acute respiratory distress and volvulus of the herniated stomach 6 months after injury. The features of this uncommon entity are discussed with special emphasis on early diagnosis. It is concluded that repeated chest radiographs during hospitalization, as well as some days after discharge, should be obtained in trauma patients to detect a slowly increasing herniation.     

LAPAROSCOPY IN THE MANAGEMENT OF DIAPHRAGMATIC RUPTURE DUE TO BLUNT TRAUMA

Background : Traumatic diaphragmatic rupture remains diagnostic challenge often unrecognized until laparotomy in over 40% of patients and the diagnosis is delayed in further 15%. This report describes four patients diagnosed at laparoscopy with ruptured diaphragm. Methods : One patient had left diaphragmatic rupture amenable to laparoscopic repair in the emergency setting. Three patients underwent laparoscopy 2, 7 and 10 days after injury which revealed two right-sided and one extensive left-sided rupture, respectively; each required open repair. Results : While laparoscopy is an excellent diagnostic tool, particularly in the delayed setting, repair is not possible for right-sided ruptures because of the liver bulk. Conclusions : Thoracoscopy in the instance of delayed presentation may offer the best chance for minimal-access diagnosis and treatment when there is suspicion of right-sided diaphragmatic rupture.     

Strangulated diaphragmatic hernia: A clinical study

Symptoms, signs, and definitions of strangulation and incarceration in diaphragmatic herniation are surveyed, and four patients with strangulated diaphragmatic hernia are reported on. Although the symptoms may be uncharacteristic, the diagnosis is easily made, if kept in mind. X-ray examination of the chest, possibly supplemented by a barium meal, usually indicates the diagnosis. The mortality rate in our series was high, similar to the findings in other series in the literature. Since approximately half of the cases of incarcerated and/ or strangulated diaphragmatic hernia are due to overlooked traumatic diaphragmatic rupture, we stress the importance of diagnosing and treating such rupture promptly to reduce the mortality rate.Strangulated diaphragmatic hernia is a clinical entity on the borderline between the fields of thoracic and general surgery. The disorder is often overlooked or improperly treated, possibly because most units have limited experience with this particular phenomenon.     

Post-traumatic tension faecopneumothorax in a young male: case report

Diaphragmatic rupture due to trauma is both well recognised and uncommon. The difficulties in diagnosing traumatic diaphragmatic rupture at the first admission are the most common causes of latent morbidity and mortality. Herniation of the abdominal viscera is the most common sequel with strangulation and perforation the most serious complication. This case outlines the delayed presentation of diaphragmatic rupture and herniation presenting as an acute tension faecopneumothorax. We review the relevant literature, with particular emphasis on the difficulties in diagnosis at presentation.     

Right uncontrollable haemothorax revealing a liver injury with diaphragmatic rupture

We report a case of a woman with a blunt thoracic trauma and haemorrhagic shock after a road traffic accident. The clinical and complementary examinations revealed an isolated right haemothorax, which was compressive and uncontrollable. The source of bleeding was discovered with delay and during a surgical exploration: it was a liver injury with diaphragmatic rupture but without hepatic herniation and peritoneal effusion. The diagnostic features of blunt diaphragmatic rupture are discussed.     

Laparoscopic repair of a ruptured diaphragm secondary to blunt trauma

The diagnosis of acute diaphragmatic rupture can be a challenge for even the most experienced clinician. The treatment of the rupture and its concomitant injuries, particularly in the elderly, can be associated with significant morbidity and mortality. The advent of laparoscopy for both the diagnosis and repair of this condition has allowed a more minimally invasive approach. We present the case of a 70-year-old woman who was hurt in a motor vehicle crash. On admission, her physical exam showed left upper quadrant tenderness and bruising. The chest radiograph was suggestive of a ruptured diaphragm. She was taken to the operating room and explored laparoscopically. After a thorough exploration of all the abdominal contents, a tear in the diaphragmatic hiatus to the right of the esophagus was noted. The stomach and small intestine were returned to the abdomen, and the diaphragmatic rupture was repaired. We conclude that laparoscopic exploration and repair of a ruptured diaphragm in a bluntly injured patient is a safe and effective option in selected cases.     

Delayed hepatothorax due to right-sided traumatic diaphragmatic rupture

We present a 48-year-old man with delayed hepatothorax due to right-sided traumatic diaphragmatic rupture. An initial chest radiograph showed no specific signs except elevation of the right diaphragmatic border. The diagnosis was confirmed by coronal reformatted helical computed tomography (CT) imaging, which revealed intrathoracic displacement of the liver. A follow-up chest radiograph revealed gradual elevation of the right diaphragmatic border, suggesting worsening of the diaphragmatic rupture and progression of hepatothorax, resulting in severe atelectasis of the right lung. Therefore, surgical repair of the diaphragmatic rupture was performed. Impaction of the liver through the diaphragmatic ruptured region was observed. Chest radiographic examination after the operation revealed a more normal position of the right diaphragmatic border and resolution of the right lung atelectasis. The problems associated with the diagnosis and operative treatment of hepatothorax with right-sided traumatic diaphragmatic ruptures are discussed in the light of this case report.