Late presenting congenital diaphragmatic hernia

Delayed herniation of the abdominal contents through a congenital diaphragmatic hernia may occur beyond the neonatal period. The case is reported of a 9 month old child presenting with acute respiratory distress secondary to tension gastrothorax. The chest radiograph showed a tension gastrothorax. Nasogastric tube placement confirmed herniation of the stomach into the left chest and is the initial treatment of choice when a tension gastrothorax is identified. The late presenting congenital diaphragmatic hernia poses considerable diagnostic challenges often leading to misdiagnosis and risk of thoracocentesis. The possibility of late presenting congenital diaphragmatic hernia should be considered in unusual cases of pneumothorax, especially in the absence of trauma so that unnecessary procedures like chest tube drainage can be avoided.     

Delayed presentation of traumatic diaphragmatic hernia

More than 111 patients with traumatic diaphragmatic hernia (TDH) were treated in a 5 1/2-year period; eight (7.2%) were first recognized more than 30 days postinjury. All were men, and their average age was 33.4 years. Seven injuries were on the left side; one was on the right side. The mechanism of injury was equally divided between penetrating and blunt trauma. Chest roentgenographic abnormalities were seen in all patients. Visceral reduction and diaphragmatic repair, despite strangulation in four patients, was accomplished without mortality and with minimal morbidity. Delayed presentation of TDH is reviewed, emphasizing diagnostic features encountered in the emergency department (ED).     

Delayed presentation of traumatic diaphragmatic rupture

We present the case of a 57-year-old woman who suffered a delayed presentation of a traumatic diaphragmatic rupture (TDR). Because TDR is frequently missed on initial presentation, a delay between trauma and diagnosis can present a unique diagnostic dilemma for the emergency physician. Important historical clues and physical examination findings are the keys to making this diagnosis.     

13例闭合性创伤性膈肌破裂临床分析

目的研究老年人闭合性创伤性膈肌破裂的临床特点。方法回顾性分析本科1996—2005年收治的闭合性创伤性膈肌破裂13例老年患者(年龄≥65岁)和46例中青年患者(年龄＜65岁)的临床病例资料,就年龄、性别、伴随疾病、创伤程度评分(ISS评分)、膈肌破裂长度、手术前延误(入院24 h内未手术)发生率、手术后并发症及病死率等指标比较和分析两者结果的异同。结果与中青年组相比较,老年组基础疾病发生率高,初诊时胸部X片未发现异常的病例数更多,手术前延误发生率显著增加,膈肌破裂长度偏短[(5．6±2．3)cm vs(10．0±6．0)cm,P＜0．05],手术后机械通气时程更长[(17．7±21．2)d vs(3．2±5．0)d,P＜0．01],手术后并发肺炎发生率更高,死亡率远高于前组。两组创伤程度评分差异无统计学意义。结论老年组由于膈肌破裂长度偏短以及机械通气、初诊时胸部X片未发现异常的病例数显著增多,从而导致手术前延误发生率显著增加;进而需要更长时间的手术后机械通气,更易并发手术后肺炎,加之基础疾病发生率高,因而病死率显著增高。     

MRI diagnosis of delayed presentation of traumatic diaphragmatic hernia

Traumatic rupture of the diaphragm may go unrecognized in patients with multiple injuries to the abdomen and chest. The majority of undiagnosed diaphragmatic ruptures will eventually become symptomatic and are associated with a high mortality rate if not treated immediately. Multiplanar imaging with magnetic resonance (MR) provided a definitive diagnosis of delayed presentation of traumatic diaphragmatic hernia.     

Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma

Abdominal injury from significant blunt trauma can include injury to bowel, kidneys, liver, and spleen. In approximately 5% of all injuries one of the diaphragms is ruptured. Diaphragmatic rupture may not be easily detected and this can lead to significant morbidity and even mortality. Rupture may be suggested on chest X-ray film especially with abnormal nasogastric tube location but the accuracy of this method is modest only. Abdominal computed tomography is not accurate and magnetic resonance imaging, although very sensitive and specific, is not feasible in most trauma situations. Surgeons have often resorted to exploratory laparotomy or laparoscopy to make the diagnosis. Although not typically part of the basic Focused Abdominal Sonography for Trauma (FAST) examination, ultrasonographic diagnosis of diaphragmatic rupture is possible with little added time to the examination. We present 3 cases of diaphragmatic rupture discovered shortly after the patients' arrival, on initial trauma evaluation with the FAST. A discussion of previous literature and ultrasound technique for diagnosis follows the cases.     

Tension pneumothorax as a presentation of traumatic diaphragmatic hernia.

Spontaneous pneumothorax and tension pneumothorax are being increasingly recognized as complications of traumatic diaphragmatic hernia, particularly when presentation is delayed. This underscores the importance of suspecting the diagnosis of diaphragmatic hernia in patients with a recent or remote history of blunt or penetrating trauma to the chest or abdomen and an unusual or an atypical thoracic process. Once the diagnosis is suspected, confirmation with contrast studies, CT, or MRI should be obtained and surgical repair undertaken without delay.     

创伤性膈疝膈肌破口形态MSCT成像研究

目的：研究创伤性膈疝（TDH）膈肌破口MSCT成像方法及其形态特征。材料与方法：回顾分析27例TDH影像资料,其中顿伤性膈疝21例（均手术证实）,医源性膈疝6例（2例手术证实）。27例均行MSCT容积扫描,采用多平面重组（MPR）倾斜法、投影法及线段法观察膈肌破口显示情况、形态特征并作比较。结果：27例膈肌破口倾斜法显示21例（77.8%）,投影法和线段法冠矢状位显示相同,分别为24例（88.9%）、20例（74.1%）,平均77.2%。27例中共26例次破口形态显示不清,其中右侧11例次36.7%（11/30）,左侧15例次（14.3%,15/105）,t=6.51,P＜0.05。破口形态主要有类圆形和椭圆形/梭形两类,其中显示为类圆形倾斜法16例（59.3%）,投影法20例次（45.5%）,线段法26例次（59.1%）;显示为椭圆形/梭形倾斜法11例（40.7%）、投影法24例次（54.5%）和线段法18例次（40.9%）。结论：MSCT MPR能直接或间接显示绝大多数TDH膈肌破口形态,倾斜法和线段法显示情形相似,较投影法更客观真实。     

Left and right lung volumes in fetuses with diaphragmatic hernia.

OBJECTIVE: To compare the volume of the ipsilateral and contralateral lungs in fetuses with congenital diaphragmatic hernia (CDH). METHODS: Left and right lung volumes were measured using three-dimensional (3D) ultrasonography in 42 fetuses with CDH at median 26 (range, 20-32) weeks of gestation. Each value was then expressed as a difference, in standard deviations, from the normal mean for gestation, previously established from the study of 650 normal fetuses at 12-32 weeks (Z-score). The Mann-Whitney U-test was used to determine the significance of the differences between the measurements in fetuses with CDH and normal fetuses and between the ipsilateral and contralateral lungs in fetuses with left- and right-sided CDH. RESULTS: There were 34 fetuses with left-sided CDH and eight with right-sided CDH. In CDH both the ipsilateral and contralateral lung volumes were substantially lower than in normal fetuses. In left CDH the left lung volume was 4.03 (median; range, 3.11-4.78) SDs below the normal mean for gestation, and the respective values for the right lung were 3.04 (median; range, 1.78-4.31) SDs (P < 0.001 for both). In right CDH, the left lung volume was 2.91 (median; range, 1.62-4.07) SDs below the normal mean for gestation and the respective values for the right lung were 4.35 (median; range, 3.07-4.99) SDs (P < 0.001 for both). In both left and right diaphragmatic hernia the deficit in the volume of the ipsilateral lung was significantly greater than the deficit in the contralateral lung. CONCLUSIONS: In fetuses with CDH both the ipsilateral and contralateral lung volumes are substantially lower than in normal fetuses.     

Sonographic diagnosis of appendicitis within a right inguinal hernia (Amyand's hernia)

We report a case of acute appendicitis occurring within a right inguinal hernia-also known as Amyand's hernia-in a 59-year-old man. The correct diagnosis was made via preoperative inguinal sonography and was confirmed via CT, allowing prompt appropriate surgical management.