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A case of intestinal obstruction A 62-year-old male presented with a 3 days of colicky abdominal pain and vomiting. He had no past medical history other than a motor vehicle accident 2 years prior. On examination, he was unwell with dehydration, tachycardia and a tender distended abdomen. Blood work showed an elevated white cell count with a C-reactive protein of 17 mg/L and mild hyponatraemia. Plain abdominal X-ray (Fig. 1a) was suggestive of large bowel obstruction, and transverse computed tomography (Fig. 1b) confirmed large bowel obstruction with a transition point at level of splenic flexure.

Colonoscopy with endoluminal stent insertion was planned and performed as a bridge to surgery. At the region of the splenic flexure there was evidence of angulation and narrowing, which prevented further insertion of the scope, but no mucosal abnormality was apparent. A decision was made to proceed with stent placement in order to decompress the proximal colon. Fluoroscopy confirmed satisfactory stent placement with a ‘waist’, and fluid and gas were seen to issue from the distal end. The patient did not improve clinically post-stent placement, and an abdominal X-ray was performed (Fig. 2). The X-ray showed that the stent was positioned high in the abdomen and numerous left-sided rib fractures were noted. Further review of coronal computed tomography scan images by an experienced radiologist (Fig. 3) revealed a defect in the left hemidiaphragm through which colon was herniating, with constriction at the hernia neck causing luminal obstruction. At subsequent laparotomy, a post-traumatic diaphragmatic hernia was present, and the splenic flexure was adherent within the chest. Partial left-sided colectomy and diaphragmatic hernia repair was performed, and the patient made an uneventful recovery. This case illustrates how crucial careful review of all available radiological images by experienced staff, prior to interventional procedures, can be. Diaphragmatic hernia can be congenital or acquired and the latter may be associated with previous thoroco-abdominal surgery, but usually arises following significant penetrating injury or external

Fig. 1. (a) Plain abdominal X-ray on admission. (b) Abdominal computed tomography on admission, which showed large bowel obstruction with a transition point at level of splenic flexure. C is labelled as colon.

Fig. 2. Plain abdominal X-ray post-stent insertion. Stent was positioned high in the abdomen and numerous left-sided rib fractures were noted (arrow).

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by colon, small bowel, spleen and abdominal omentum.4 Presentation and symptoms depend on the organ involvement and surgical intervention is often imperative. Mortality can be as high as 80% when gastrointestinal ischaemia occurs, and prompt surgery is therefore required.2 Abnormality of the diaphragmatic contour on chest radiographs may be present,5 but early diagnosis with appropriate management can be difficult when the original injury is remote and clinicians do not consider the possibility of this diagnosis. Detailed history combined with careful review of the radiological imaging is required to prevent a delayed diagnosis with resultant mortality and morbidity.

References

Fig. 3. A defect in the left hemi-diaphragm through which colon was herniating, with constriction at the hernia neck causing luminal obstruction.

blunt injury, particularly on the left side.1 The incidence of diaphragmatic hernia is 0.8 to 5.0% in blunt abdominal trauma and 1.5% in blunt thoracic trauma.2 In the setting of acute trauma, diaphragmatic hernia may be masked by other injuries, making diagnosis difficult. Often with time, the defect may become larger, allowing herniation of one or more abdominal organs with associated obstruction or strangulation. Herniation of abdominal contents was present in 85% of diaphragmatic hernias, and herniation of more than one organ was present in 57%.3 The stomach is the most common organ to herniate, followed

1. Hood RM. Traumatic diaphragmatic hernia. Ann. Thorac. Surg. 1971; 12: 311–24. 2. Matsevych OY. Blunt diaphragmatic rupture: four year’s experience. Hernia. 2008; 12: 73–8. 3. Kishore GS, Gupta V, Doley RP et al. Traumatic diaphragmatic hernia: tertiary centre experience. Hernia. 2010; 14: 159–64. 4. Christiansen LA, Blichert-Toft M, Bertelsen S. Strangulated diaphragmatic hernia. A clinical study. Am. J. Surg. 1975; 129: 574–8. 5. Cruz CJ, Minagi H. Large-bowel obstruction resulting from traumatic diaphragmatic hernia: imaging findings in four cases. AJR Am. J. Roentgenol. 1994; 162: 843–5.

Judy Huang,* MBChB Jagdish Prasad,† DSM, FRACS Robert Cunliffe,* BM BCh, DM, FRCP *Department of Gastroenterology, Tauranga Hospital, Tauranga, New Zealand and †Department of Surgery, Whakatane Hospital, Whakatane, New Zealand doi: 10.1111/ans.12740

© 2014 Royal Australasian College of Surgeons

A case of intestinal obstruction.

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