American Journal of Emergency Medicine 33 (2015) 1329.e1–1329.e3

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Case Report

Delayed presentation of diaphragmatic rupture with stomach herniation and strangulation☆ Abstract Blunt traumatic rupture of the diaphragm is a relatively uncommon but severe consequence that is usually seen in polytraumatized patients after thoracoabdominal trauma. Traumatic diaphragmatic rupture presents diagnostic difficulty, with basic radiological investigations discovering no more than half of all cases, whereas complications may present long after the initial injury has occurred. Late presentation is associated with increased morbidity. We herein report a rare case of diaphragmatic hernia due to missed traumatic diaphragmatic rupture in a 28-year-old man who experienced blunt thoracoabdominal trauma and presented with dyspnea and epigastric pain 4 months after his initial injury. His condition was complicated by diffuse ischemic alterations of the fundus and a part of the greater curvature of the stomach as well as questionable viability of the gastroesophageal junction. The patient had a successful emergency transabdominal suture plication of the diaphragm and a sleevelike gastrectomy. We present a case of a 28-year-old man who was admitted with nausea, vomiting, pain in the chest and upper abdomen, and breathlessness of 48 hours’ duration. He had a history of thoracoabdominal blunt trauma following a car accident 4 months previously; only a left upper limb bone fracture was found. He mentioned that the afternoon before his admission, he was playing with his young child, positioning him over his abdomen. On physical examination, the patient was anxious, had a regular tachycardia, and was dyspneic (blood pressure, 135/ 70 mm Hg; 100 beats per minute; inspiratory rate, 36/min; SpO2, 93%). Examination of the left chest showed absence of breath sounds, whereas bowel sounds were present and there was dullness on percussion. Leukocytosis (13 000/mm 3) was the only abnormal laboratory finding. The chest radiograph demonstrated an elevated left hemidiaphragm and a large air-fluid level in the left thoracic cavity (Fig. 1). Barium meal and chest computed tomography (CT) scan showed the presence of the stomach into the thoracic cavity, establishing the diagnosis of posttraumatic diaphragmatic hernia (Figs. 2 and 3). An upper midline laparotomy incision was used to access the abdominal cavity where the fundus and a part of the greater curvature of the stomach were herniated into a 5- to 6-cm diaphragmatic defect of the left hemidiaphragm (Fig. 4) with presence of diffuse ischemic alterations of the fundus and ischemia of the gastroesophageal junction (Fig. 5). The diaphragmatic defect was closed in 2 layers using nonabsorbable nylon sutures: a first layer of interrupted and a second layer

☆ Conflict of interest: none. 0735-6757/© 2015 Elsevier Inc. All rights reserved.

of continuous sutures. To avoid a disabling operation such as a total or proximal gastrectomy in a young patient, the abdomen was temporary closed and the patient was transferred to the intensive care unit. Six hours later, a second look was performed. The gastroesophageal junction was ischemic alterations free, whereas a large part of the stomach had also obtained a normal color. A sleevelike gastrectomy was performed including a minimal part of the major curvature of the stomach and the fundus. The postoperative period was uneventful, and the patient was discharged the 10th postoperative day. Incidence of traumatic diaphragmatic rupture (TDR) after thoracoabdominal trauma is estimated in 0.8% to 5% [1]. It has been reported that 12% to 60% of TDRs are misdiagnosed during the initial hospitalization and up to 30% of them are presented in delay with diaphragmatic hernia [2]. Traumatic diaphragmatic ruptures occur in 5% of hospitalized patients for road-traffic accidents, in 10% of penetrating chest trauma, and in 0.8% to 1.6% of blunt trauma [3]. It usually occurs on the left side, a fact attributed to the protective effect of the liver to the right dome of the diaphragm [4]. The mechanism of injury is attributed to the increased intraabdominal pressure. The force transmitted through the viscera to the hemidiaphragms causes shearing of the membrane and avulsion of the diaphragm from its points of attachment [5]. Delay in presentation could be based in 2 hypotheses: delayed rupture and delayed detection, whereas 3 phases of the TDR have been described: the acute phase occurs when the initial lesion takes place; the second phase is characterized by the gradual herniation of the abdominal organs into the chest and may occur over months or years; and the third phase is symptomatic and clinically evident by visceral herniation, obstruction, incarceration, or perforation [6]. In most cases, early symptoms are missed and the rupture may be identified during laparotomy for concomitants intraabdominal injuries [7]. The patient often presents with breathlessness, chest and epigastric pain, nausea, vomiting, respiratory distress, hemorrhage, and peptic ulcer [8]. Pneumothorax or hydrothorax and gastropleurocutaneous fistula are also reported as late sequelae of the rupture [9]. Chest radiograph is the initial imaging modality, presenting a sensitivity of 46% for left-sided and 17% for right-sided injuries, increased almost to 75% after nasogastric decompression [4]. Reported diagnostic sensitivity of CT scanning is 70% for left-sided and 50% for right-sided injuries, and its specificity is 100% [10]. The role of thoracoscopy and barium meal remains vital in diagnosis of diaphragmatic hernia; however, we did not perform thoracoscopy because of the nonavailability in our hospital. All cases of TDR must be repaired surgically [11]. In our case, the patient had a history of a blunt thoracoabdominal trauma 4 months ago. He probably had a misdiagnosed TDR that remained “silent” for this period. However, it is not clear if gastric

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E. Falidas et al. / American Journal of Emergency Medicine 33 (2015) 1329.e1–1329.e3

Fig. 4. Intraoperative picture showing the diaphragmatic defect. Fig. 1. Chest radiograph showing elevated left dome of the diaphragm and a large air-fluid level into the left thoracic cavity.

herniation was present before strangulation or if herniation and strangulation occurred at the same time. A possible explanation is that vomiting and the positioning of patient’s child over his abdomen increased the intraabdominal pressure, favoring herniation and strangulation of the fundus. We decided to manage the patient in a 2-stage procedure to give the time and the opportunity to the ischemic gastroesophageal junction to be reperfused. We tried to avoid a disabling operation in a young patient. Evangelos Falidas, MD Stavros Gourgiotis, MD, PhD Konstantinos Vlachos, MD, PhD Constantinos Villias, MD, PhD⁎ First Surgical Department 417 NIMTS Military Veterans’ Fund Hospital of Athens, Greece ⁎ Corresponding author at: 41 Zakinthinou St, 15669 Papagou, Athens, Greece Tel./fax: +30 2106998362 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.02.052 References

Fig. 2. Barium meal shows the presence of the stomach in the thoracic cavity.

[1] Rossetti G, Brusciano L, Maffetone V, Napolitano V, Sciaudeone G, DelGenio G, et al. Giant right post-traumatic diaphragmatic hernia: laparoscopic repair without a mesh. Chir Ital 2005;57:243–6. [2] Papas-Gogos G, Karfis E, Kakadelis J, Tsimoyiannis EC. Intrathoracic cancer of the splenic flexure. Hernia 2007;11:257–9.

Fig. 3. The chest CT reveals a visceral herniation into the thoracic cavity.

Fig. 5. Intraoperative picture showing the ischemic alterations of the fundus.

E. Falidas et al. / American Journal of Emergency Medicine 33 (2015) 1329.e1–1329.e3 [3] Shah R, Sabanathan S, Meams AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444–9. [4] Goh BK, Wong AS, Tay KH, Hoe MN. Delayed presentation of a patient with ruptured complicated by gastric incarceration and perforation after apparently minor blunt trauma. CJEM 2004;6:277–80. [5] Walchalk LR, Stanfield SC. Delayed presentation of traumatic diaphragmatic rupture. J Emerg Med 2010;39:21–4. [6] Yakaryilmaz F, Banli O, Altun H, Guliter S. Delayed presentation of post-traumatic diaphragmatic hernia with gastric volvulus: a case report. Ulus Travma Acil Cerrahi Derg 2010;16:277–9.

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[7] Sirbu H, Busch T, Spillner J, Schachtrupp A, Autschabach R. Late bilateral diaphragmatic rupture: challenging diagnostic and surgical repair. Hernia 2005;9:90–2. [8] Rashid F, Chakrabarty MM, Singh R, Iftikhar SY. A review on delayed presentation of diaphragmatic rupture. World J Emerg Surg 2009;4:32. [9] de Jager CP, Trof RJ. Images in clinical medicine. Gastrothorax simulating acute tension pneumothorax. N Engl J Med 2004;351:e5. [10] Nchimi A, Szapiro D, Ghaye B, Willems V, Khamis J, Haquet L, et al. Helical CT of blunt diaphragmatic rupture. AJR Am J Roentgenol 2005;184:24–30. [11] Neugebauer EA, Sauerland S. Guidelines for emergency laparoscopy. World J Emerg Surg 2006;1:31.

Delayed presentation of diaphragmatic rupture with stomach herniation and strangulation.

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