Clinical Review & Education
JAMA Surgery Clinical Challenge
Chest Discomfort and Longstanding Dyspnea on Exertion Ryan A. Macke, MD; Thomas P. Templin, MD; Justin D. Blasberg, MD
A Coronal reformatted, multiplanar image
B
Sagittal reformatted, multiplanar image
Borders of diaphragm defect
Figure 1. Computed tomographic scans.
A man in his early 40s was referred for surgical evaluation following abnormal imaging obtained during workup of recent left-sided chest discomfort and longstanding dyspnea on exertion. A large air-fluid level was seen on a recent chest roentgenogram, and subsequent computed tomographic scans of his chest were obtained (Figure 1). The only medical history reported was a previous umbilical hernia repair. On further discussion, it was discovered that he was involved in a motorcycle crash many years ago. Other than a brief loss of consciousness, no significant injuries were sustained per the patient’s report. He did undergo a formal trauma evaluation at that time; however, the radiographic images and medical records were no longer available. In addition to complaints of dyspnea and chest discomfort, the patient reported 5 to 6 episodes of small-volume emesis over the last 6 months. He denied any other gastrointestinal symptoms, such as heartburn, dyspnea, or constipation. The results of his examination were unremarkable, with the exception of bowel sounds being heard on auscultation of the left chest.
jamasurgery.com
WHAT IS YOUR DIAGNOSIS?
A. Type IV hiatal hernia B. Congenital diaphragmatic hernia C. Blunt traumatic rupture of the diaphragm D. Diaphragm eventration
(Reprinted) JAMA Surgery October 2016 Volume 151, Number 10
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Tufts Univ. Hirsh Health Sciences Library User on 10/25/2016
979
Clinical Review & Education JAMA Surgery Clinical Challenge
Diagnosis C. Blunt traumatic rupture of the diaphragm
Discussion This patient’s presentation was consistent with a diaphragmatic hernia or some other diaphragm disorder. The representative computed tomographic images reveal multiple abdominal viscera (stomach, small bowel, colon, spleen, and pancreas) herniated into the left chest with near-complete left-lung atelectasis (Figure 1A). Differential diagnoses included type IV hiatal hernia, congenital diaphragmatic hernia, diaphragm eventration, diaphragm paralysis, and blunt traumatic rupture of the diaphragm with delayed diagnosis. Complaints of dyspnea are common with each of these disorders owing to the intrathoracic displacement of abdominal contents with resulting restricted lung volumes. Chest radiography demonstrating air-fluid levels above the expected level of the diaphragm is also suggestive of any of these diagnoses. A detailed history and additional imaging are therefore required to determine the correct diagnosis. Computed tomography with reformatted, multiplanar images is currently the diagnostic modality of choice to detect and localize diaphragmatic defects.1,2 In this case, the selected images reveal a central left-diaphragm defect (Figure 1B), which was confirmed intraoperatively (Figure 2). Congenital diaphragmatic hernias are uncommon in adults and are found in distinctly different locations.3 Morgagni hernias result from anterior defects, typically to the right of the midline. Bochdalek hernias result from posterior diaphragmatic defects, most commonly on the left in adults. Type IV hiatal hernias can also present with impressive herniation of multiple viscera. However, herniation through a widened esophageal hiatus and upper gastrointestinal complaints are typically observed. The diaphragm is elevated but intact in cases of eventration and diaphragm paralysis. Acute blunt traumatic rupture of the diaphragm occurs in roughly 5% of blunt traumas, the majority resulting from motor vehicle crashes.4 This diagnosis can be challenging, particularly in cases of right-sided injury, conservatively managed blunt trauma, and multiple traumas with other life-threatening injuries.1,2 Imaging tech-
Author Affiliations: Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison. Corresponding Author: Ryan A. Macke, MD, Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, H4/318 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 ([email protected]). Section Editor: Pamela A. Lipsett, MD, MHPE.
980
Spleen
Left triangular ligament Stomach Liver
Figure 2. Laparoscopy of left diaphragm defect after reduction of bowel, with stomach and spleen not yet fully reduced.
nique, clinicians’ awareness of the possibility for occult diaphragm injury, and extent to which suspicion of injury is investigated affect the odds of correctly diagnosing blunt traumatic rupture of the diaphragm. Approximately 15% of cases are diagnosed in a delayed fashion, sometimes years after injury.5,6 Therefore, a history of thoracoabdominal trauma, regardless of how trivial, should raise suspicion of a late-presenting blunt traumatic rupture of the diaphragm. Larger defects are more likely to cause respiratory compromise owing to herniation of multiple viscera, whereas obstructive symptoms resulting from incarcerated bowel are more likely with smaller defects.7 In this case, herniated contents were reduced laparoscopically. A left-sided minithoracotomy was necessary to maintain reduction of abdominal viscera while primary repair with pledgetted, nonabsorbable suture was performed. The patient was discharged home on postoperative day 6 with a chest tube for drainage of a persistent pleural effusion. The tube was removed in the clinic 1 week later. Recovery was otherwise uncomplicated. The patient reported resolution of symptoms and improved exercise capacity at long-term follow-up.
Conflict of Interest Disclosures: None reported.
ARTICLE INFORMATION
Published Online: August 10, 2016. doi:10.1001/jamasurg.2016.2043.
Anterior border of left diaphragm defect
REFERENCES 1. Desir A, Ghaye B. CT of blunt diaphragmatic rupture. Radiographics. 2012;32(2):477-498. 2. Bocchini G, Guida F, Sica G, Codella U, Scaglione M. Diaphragmatic injuries after blunt trauma: are they still a challenge? reviewing CT findings and integrated imaging. Emerg Radiol. 2012;19(3):225235. 3. Congenital diaphragmatic malformations. In: Patterson GA, Cooper JD, Deslauriers J, Rice TW, Luketich JD, Lerut A, eds. Pearson’s Thoracic and Esophageal Surgery. 3rd ed. London, England: Churchill Livingstone; 2008:1401-1412.
4. Chughtai T, Ali S, Sharkey P, Lins M, Rizoli S. Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases. Can J Surg. 2009;52(3):177-181. 5. Ozpolat B, Kaya O, Yazkan R, Osmanoğlu G. Diaphragmatic injuries: a surgical challenge. Report of forty-one cases. Thorac Cardiovasc Surg. 2009; 57(6):358-362. 6. Singh S, Kalan MMH, Moreyra CE, Buckman RF Jr. Diaphragmatic rupture presenting 50 years after the traumatic event. J Trauma. 2000;49(1):156-159. 7. Naunheim KS. Adult presentation of unusual diaphragmatic hernias. Chest Surg Clin N Am. 1998; 8(2):359-369.
JAMA Surgery October 2016 Volume 151, Number 10 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Tufts Univ. Hirsh Health Sciences Library User on 10/25/2016
jamasurgery.com
JAMA Surgery Clinical Challenge
Chest Discomfort and Longstanding Dyspnea on Exertion Ryan A. Macke, MD; Thomas P. Templin, MD; Justin D. Blasberg, MD
A Coronal reformatted, multiplanar image
B
Sagittal reformatted, multiplanar image
Borders of diaphragm defect
Figure 1. Computed tomographic scans.
A man in his early 40s was referred for surgical evaluation following abnormal imaging obtained during workup of recent left-sided chest discomfort and longstanding dyspnea on exertion. A large air-fluid level was seen on a recent chest roentgenogram, and subsequent computed tomographic scans of his chest were obtained (Figure 1). The only medical history reported was a previous umbilical hernia repair. On further discussion, it was discovered that he was involved in a motorcycle crash many years ago. Other than a brief loss of consciousness, no significant injuries were sustained per the patient’s report. He did undergo a formal trauma evaluation at that time; however, the radiographic images and medical records were no longer available. In addition to complaints of dyspnea and chest discomfort, the patient reported 5 to 6 episodes of small-volume emesis over the last 6 months. He denied any other gastrointestinal symptoms, such as heartburn, dyspnea, or constipation. The results of his examination were unremarkable, with the exception of bowel sounds being heard on auscultation of the left chest.
jamasurgery.com
WHAT IS YOUR DIAGNOSIS?
A. Type IV hiatal hernia B. Congenital diaphragmatic hernia C. Blunt traumatic rupture of the diaphragm D. Diaphragm eventration
(Reprinted) JAMA Surgery October 2016 Volume 151, Number 10
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Tufts Univ. Hirsh Health Sciences Library User on 10/25/2016
979
Clinical Review & Education JAMA Surgery Clinical Challenge
Diagnosis C. Blunt traumatic rupture of the diaphragm
Discussion This patient’s presentation was consistent with a diaphragmatic hernia or some other diaphragm disorder. The representative computed tomographic images reveal multiple abdominal viscera (stomach, small bowel, colon, spleen, and pancreas) herniated into the left chest with near-complete left-lung atelectasis (Figure 1A). Differential diagnoses included type IV hiatal hernia, congenital diaphragmatic hernia, diaphragm eventration, diaphragm paralysis, and blunt traumatic rupture of the diaphragm with delayed diagnosis. Complaints of dyspnea are common with each of these disorders owing to the intrathoracic displacement of abdominal contents with resulting restricted lung volumes. Chest radiography demonstrating air-fluid levels above the expected level of the diaphragm is also suggestive of any of these diagnoses. A detailed history and additional imaging are therefore required to determine the correct diagnosis. Computed tomography with reformatted, multiplanar images is currently the diagnostic modality of choice to detect and localize diaphragmatic defects.1,2 In this case, the selected images reveal a central left-diaphragm defect (Figure 1B), which was confirmed intraoperatively (Figure 2). Congenital diaphragmatic hernias are uncommon in adults and are found in distinctly different locations.3 Morgagni hernias result from anterior defects, typically to the right of the midline. Bochdalek hernias result from posterior diaphragmatic defects, most commonly on the left in adults. Type IV hiatal hernias can also present with impressive herniation of multiple viscera. However, herniation through a widened esophageal hiatus and upper gastrointestinal complaints are typically observed. The diaphragm is elevated but intact in cases of eventration and diaphragm paralysis. Acute blunt traumatic rupture of the diaphragm occurs in roughly 5% of blunt traumas, the majority resulting from motor vehicle crashes.4 This diagnosis can be challenging, particularly in cases of right-sided injury, conservatively managed blunt trauma, and multiple traumas with other life-threatening injuries.1,2 Imaging tech-
Author Affiliations: Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison. Corresponding Author: Ryan A. Macke, MD, Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, H4/318 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 ([email protected]). Section Editor: Pamela A. Lipsett, MD, MHPE.
980
Spleen
Left triangular ligament Stomach Liver
Figure 2. Laparoscopy of left diaphragm defect after reduction of bowel, with stomach and spleen not yet fully reduced.
nique, clinicians’ awareness of the possibility for occult diaphragm injury, and extent to which suspicion of injury is investigated affect the odds of correctly diagnosing blunt traumatic rupture of the diaphragm. Approximately 15% of cases are diagnosed in a delayed fashion, sometimes years after injury.5,6 Therefore, a history of thoracoabdominal trauma, regardless of how trivial, should raise suspicion of a late-presenting blunt traumatic rupture of the diaphragm. Larger defects are more likely to cause respiratory compromise owing to herniation of multiple viscera, whereas obstructive symptoms resulting from incarcerated bowel are more likely with smaller defects.7 In this case, herniated contents were reduced laparoscopically. A left-sided minithoracotomy was necessary to maintain reduction of abdominal viscera while primary repair with pledgetted, nonabsorbable suture was performed. The patient was discharged home on postoperative day 6 with a chest tube for drainage of a persistent pleural effusion. The tube was removed in the clinic 1 week later. Recovery was otherwise uncomplicated. The patient reported resolution of symptoms and improved exercise capacity at long-term follow-up.
Conflict of Interest Disclosures: None reported.
ARTICLE INFORMATION
Published Online: August 10, 2016. doi:10.1001/jamasurg.2016.2043.
Anterior border of left diaphragm defect
REFERENCES 1. Desir A, Ghaye B. CT of blunt diaphragmatic rupture. Radiographics. 2012;32(2):477-498. 2. Bocchini G, Guida F, Sica G, Codella U, Scaglione M. Diaphragmatic injuries after blunt trauma: are they still a challenge? reviewing CT findings and integrated imaging. Emerg Radiol. 2012;19(3):225235. 3. Congenital diaphragmatic malformations. In: Patterson GA, Cooper JD, Deslauriers J, Rice TW, Luketich JD, Lerut A, eds. Pearson’s Thoracic and Esophageal Surgery. 3rd ed. London, England: Churchill Livingstone; 2008:1401-1412.
4. Chughtai T, Ali S, Sharkey P, Lins M, Rizoli S. Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases. Can J Surg. 2009;52(3):177-181. 5. Ozpolat B, Kaya O, Yazkan R, Osmanoğlu G. Diaphragmatic injuries: a surgical challenge. Report of forty-one cases. Thorac Cardiovasc Surg. 2009; 57(6):358-362. 6. Singh S, Kalan MMH, Moreyra CE, Buckman RF Jr. Diaphragmatic rupture presenting 50 years after the traumatic event. J Trauma. 2000;49(1):156-159. 7. Naunheim KS. Adult presentation of unusual diaphragmatic hernias. Chest Surg Clin N Am. 1998; 8(2):359-369.
JAMA Surgery October 2016 Volume 151, Number 10 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Tufts Univ. Hirsh Health Sciences Library User on 10/25/2016
jamasurgery.com
