0ASE REPORT diaphragmatic hernia, intrapericardial

Delayed Presentation of Intrapericardial Diaphragmatic Hernia, an Unusual Cause of Colon Obstruction The earliest symptoms of diaphragmatic hernia m a y not appear until viscera incarcerate in it years after the causal injury. The most unusual site for a diaphragmatic hernia to occur is through the central tendon of the diaphragm into the pericardium. We present the case of a 43-year-old man who suffered a bowel obstruction when the transverse colon and omentum became incarcerated in the intrapericardial diaphragmatic hernia. The defect presumably resulted from blunt chest and abdominal trauma received 15 years earlier. The delayed presentation of intrapericardial diaphragmatic hernia is reviewed, and recommendations for evaluation and treatment are made. [Beless D J, Organ BC: Delayed presentation of intrapericardiaI diaphragmatic hernia, an unusual cause of colon obstruction. Ann Emerg Med April 1991;20:415-417.] INTRODUCTION The delayed phase of a diaphragmatic hernia may present years after a patient's initial injury. The patient may be asymptomatic or complain of seemingly unrelated symptoms, which may even mimic heart disease, before diagnosis. Finally, a patient may develop symptoms of bowel obstruction. A unique subgroup of hernias exists in which the diaphragmatic rent communicates with the pericardium. This rare phenomenon most often results from either blunt or penetrating trauma, although congenital defects have been described. Our case illustrates an unusual cause of colon obstruction. The transverse colon and omentum herniated through a defect in the diaphragm into the pericardial sac and subsequently became incarcerated. This defect presumably was caused by blunt trauma that occurred 15 years earlier. A comprehensive literature search revealed approximately 60 cases of intrapericardial diaphragmatic hernia, with approximately half presenting in the delayed phase.

Daniel J Beless, MD, FACEP* Brian C Organ, MDt Atlanta, Georgia. From the Division of Emergency Medicine, Department of Community and Preventive Medicine,* and the Department of Surgery,¢ Crawford Long Hospital, Emory University School of Medicine, Atlanta, Georgia. Received for publication July 26, 1990. Accepted for publication October 8, 1990. Address for reprints: Daniel Beless, MD, FACER Division of Emergency Medicine, Crawford Long Hospital, 550 Peachtree Street, Atlanta, Georgia 30365.

CASE PRESENTATION A 43-year-old man presented to the emergency department complaining of lower abdominal pain of three days' duration. The pain began gradually, slowly increased in intensity, and finally became most prominent in the lower right quadrant. He complained of steady pain with periods of intense cramping. He had developed nausea and vomiting 24 hours after the onset of pain. The patient denied having a bowel movement for more than three days despite the use of laxatives and an enema. Twice previously, he was evaluated during this period at another facility and was diagnosed with c o n s t i p a t i o n and a viral illness. Ibuprofen and p r o p o x y p h e n e w i t h acetaminophen prescribed during these visits had provided no relief. He denied fever or chills. The patient's medical history was significant only for an overnight hospitalization 15 years earlier for observation after a motor vehicle accident. He had suffered blunt trauma to his chest from the steering wheel but knew of no fracture or other injuries. He had no history of surgery or penetrating trauma. He described occasional chest pains, which he dismissed as "gas," and complained of being easily fatigued. Physical examination revealed a moderately uncomfortable middle-aged man who had an oral temperature of 36.5 C. Vital signs included a blood

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FIGURE 1. Upright chest radiograph. FIGURE 2. Supine abdomen radio-

graph. FIGURE 3. Upright abdomen radio-

graph. pressure of 121/87 m m Hg, which did not change from supine to upright, but his pulse increased from 91 to 113. Respirations were 20 and unlabored. Examination of the chest was unremarkable. The abdomen appeared mildly distended, and auscultation showed hypoactive bowel sounds. Palpation of the abdomen d e m o n s t r a t e d t e n d e r n e s s in the lower right quadrant; however, it was not well localized, and there was no rebound. Rectal e x a m i n a t i o n revealed minimal stool in the vault, which was guaiac-negative. I n i t i a l l a b o r a t o r y r e s u l t s were WBCs of 8.6 x 103/mm; hematocrit, 48.4%; BUN, 20 mg/dL, creatinine, 1.1 mg/dL; and electrolytes, normal. Radiographs of the chest and abdomen demonstrated air-distended cecum and transverse colon with app a r e n t o b s t r u c t i o n at t h e m i d transverse colon. Also noticeable was an air fluid level above the diaphragm behind the cardiac silhouette, which appeared to be an extension of the transverse colon (Figures 1 to 3). The patient's ECG demonstrated a sinus rhythm with a late R wave transition in the precordial leads, but it was otherwise normal. The ED a s s e s s m e n t was large bowel obstruction secondary to an incarcerated diaphragmatic hernia. 124/416

General surgery was consulted. IV fluids and antibiotics were begun. A Gastrograffin ® enema demonstrated complete o b s t r u c t i o n of the midtransverse colon consistent with herniation through a diaphragmatic defect; no mass lesions or polyps were noted. The patient was taken to the operating room, and laparotomy was performed through a midline incision, which would allow extension of the incision into the chest through median sternotomy if required. Exploration revealed dilated transverse colon that herniated through a 6- to 7-cm rent in the anterior diaphragm just left of the midline. The large bowel was gently retracted back into the abdominal cavity, and adhesions were lysed. The hernia contained a large segment of midtransverse colon as well as 50% of the greater omentum. The defect in the diaphragm communicated directly into the pericardial sac. There was no evidence of communication with the pleural cavities. The bowel showed no evidence of ischemia. The diaphragmatic defect was closed with interrupted 2-0 polypropylene suture. Postoperatively, the patient had a pericardial friction rub and minor diffuse elevation in ST segments on ECG consistent with pericarditis; otherwise, he had an uneventful recovery. At outpatient follow-up, the patient remarked that he had not felt so good in years. DISCUSSION

In 1951, Carter et al grouped the Annals of Emergency Medicine

initial presentation of traumatic diaphragmatic hernias into three clinical phases: acute, interval, and obstructive. 1 The latter two groups have since been termed the delayed phase of presentation. 2 This may occur months to many years after the initial injury. One of the earliest historical descriptions of delayed complications of traumatic diaphragmatic hernia was by Ambrose Par4 in 1579. He described an artillery captain who lived for eight months after a gunshot wound through the chest. On p o s t m o r t e m examination, the transverse colon was found to have herniated through the diaphragm, resulting in strangulation.3, 4 T r a u m a t i c defects in the diaphragm, both large and small, usually do not close spontaneously because of the relative negative pressure gradient between the thoracic and abdominal cavities. A defect that is relatively small at the time of initial injury may enlarge slowly or suddenly under the strain of lifting or coughing. Diaphragmatic tears may be the result of penetrating or blunt trauma. D u r i n g b l u n t a b d o m i n a l trauma, intraperitoneal pressure may increase to 1,000 cm H20 from a normal value of +2 to +10 cm H20 , bursting a rent in the diaphragm, s Diaphragmatic hernias occurring as a result of blunt trauma are most common on the left side. s This is probably because the liver cushions the right side of the diaphragm, reducing the chance of tearing at the time of injury. This case is an example of an u n 20:4 April 1991

HERNIA Beless & Organ

usual subgroup of t r a u m a t i c diaphragmatic hernias in which the defect occurs in the central tendon of the diaphragm, with herniation directly into the pericardial sac. This is the rarest type of diaphragmatic hernia because of the extra strength in the pericardial diaphragm as well as the cushioning action against the heart. The earliest documentation of this type of hernia occurred in the early 1900s, when the diagnosis was made at autopsy. 6 An intrapericardial diaphragmatic hernia may present in either the acute or delayed phase. When the hernia results from blunt trauma, there f r e q u e n t l y m a y be other substantial injuries as well. Extensive ruptures into the pericardium cause almost i m m e d i a t e symptoms of respiratory distress or hypotension, requiring emergency repair.Z,8 Herniation of visceral contents into the pericardial sac may result in acute tamponade. If symptoms resembling acute tamponade occur in this clinical situation, external chest compression may temporarily reduce the hernia contents sufficiently to allow urgent surgical repair to be made. 9 Needle pericardiocentesis would be ineffective and contraindicated if intrapericardial hernia is suspected. The delayed presentation results when a previously small defect enlarges to the extent that the individual becomes symptomatic from progressive herniation. In Van Loenhout et al's review of 58 cases in the literature, approximately equal numbers of patients presented in the delayed phase as in the acute, with the average interval between injury and treatment being 2.3 years, s Their presentation range was from 23 days to 23 years. In older patients, symptoms such as dyspnea, chest pain, and fatigue may be erroneously presumed to be cardiac in origin.lO, 11 If bowel gas is not seen above the diaphragm on chest radiograph% the cardiac silhouette may appear enlarged, supporting that incorrect diagnosis. When viscera become incarcerated into the diaphragmatic defect, signs and symptoms of intestinal obstruction predominate. The o m e n t u m is usually the first to herniate, followed by transverse colon, stomach, small bowel, or liver. 12 The conspicuous s y m p t o m s of o b s t r u c t i o n m a y so dominate the history that a description of prior trauma may be over20:4 April 1991

looked. Graivier and Freeark suggested that a delayed presentation of diaphragmatic hernia should be considered if any of the following criteria are present: intestinal obstruction and a history of chest or abdominal trauma, intestinal o b s t r u c t i o n w i t h radiological findings such as a left pleural diaphragmatic density, bowel obstruction without scars or palpable abdominal hernia, or large bowel obstruction in young individualsJ 3 Our patient fit several of these criteria. When air shadows within hollow viscera are present above the diaphragm, plain radiographs of the chest may be the initial method of diagnosis. Barium contrast studies may result in cardiac tamponade should the barium be instilled under pressure distending the hollow viscous w i t h i n the enclosed pericardium. 14 Contrast studies should be undertaken with caution only when the diagnosis is unsuspected or when other means are unavailable. 5 Computed t o m o g r a p h y has been used since 1979 for the investigation of traumatic hernias and may be particularly useful if obstruction is suspected; ls,16 it is probably the method of choice for evaluation if there is suspicion of a pericardial hernia. An echocardiogram may also be useful if intrapericardial h e r n i a t i o n is suspected. 17 A traumatic diaphragmatic hernia has no peritoneal sac. Adhesions among the herniating viscera and pericardial and pleural structures develop rapidly, necessitating the utmost care during surgical repair. 13 There has been controversy concerning the best surgical approach to reduce and repair diaphragmatic hernias. In the case of intrapericardial diaphragmatic hernias, a transabdominal approach is best. 6 It provides the best exposure of the diaphragmatic defect for repair and all o w s c o m p l e t e e x a m i n a t i o n of abdominal viscera. A transthoracic approach requires cardiac displacement and incision of the lateral pericardium and hemidiaphragm. In addition, intrapericardial diaphragmatic hernias have been overlooked at thoracotomy. S A midline anterior abdominal incision may be extended to s t e r n o t o m y if t h o r a c o t o m y is required for lysis of adhesions. 17 Repair of the defect by closure with nonabsorbable sutures is effective. Annals of Emergency Medicine

SUMMARY The emergency physician m u s t have a high degree of suspicion and inquire about prior trauma to make the diagnosis of delayed traumatic diaphragmatic hernia. Intrapericardial herniation is a rare form of diaphragm a t i c herniation. S y m p t o m s m a y mimic cardiac disease for years before the correct diagnosis. Intestinal obstruction may result from incarceration of viscera into the hernia years after the initial injury occurred. Because the herniated viscera may be contained within the pericardial sac, aggressive barium contrast studies may cause acute cardiac tamponade. The suspicion of intrapericardial diaphragmatic hernia should be a contraindication to the routine use of barium enema to evaluate colonic obstruction.

REFERENCES 1. Carter BN, Giuseffi J, Telson G: Traumatic diaphragmatic hernia. Am f RoentgenoI 1951i65:56-72. 2. Stmg B, Noon GP, Beall AC: Traumatic diaphragmatic hemia. Ann Thorac Surg 1974;17:444-449. 3. Johnson T: The Works of That Famous Chirugeon. Ambrose Fare. London, vol 10, 1678, p 259, T Cotis, R Young. 4. Schwindt WD, Gale JW: Late recognition and treatment of traumatic diaphragmatic hernias. Arch Surg 1967~94:330-334. 5. van Loenhout RM, Schiphorst TJ, Wittens CH, et al: T r a u m a t i c intrapericardial diaphragmatic hernia. J Trauma 1986;26:271-275. 6. Meng RL, Strans A, Milloy A, et al: Intrapericardial diaphragmatic hernia in adults. Ann Surg 1979;189: 359-366. 7. Coats RR, Sakai K, Lam CR, et al: Extensive diaphragmatic-pericardial rupture from blunt trauma. Thorac Cardiovasc Surg 1972;63:275-278. 8. Slung HB, Raman VK, Ibrahim A~ et al: Traumatic diaphragmatic rupture involving the pericardium. South Med J 1983;76:1459-1460. 9. Beddingfield GW: Cardiac tamponade due to traumatic hemia of the diaphragm and pericardium. Ann Thorac Surg 1968;6:178-180. 10. Stein J, Colmore HP, Green RA: Diaphragmaticopericardial tear with intrapericardial herniation of transverse colon. Radiology 1953~60:417-419. 11. Moore TC: Traumatic pericardial diaphragmatic hernia. Arch Surg 1959~79:827-831. 12. Smith L, Lippert KM: Peritoneo-pericardial diaphragmatic hernia. Ann Surg 1958fl48:798-804. 13. Graivier L, Freeark Rlz: Traumatic diaphragmatic hernia. Arch Surg 1963~86:363-373. 14. Adamthwaite DN, Snijders DC, Mirwis J: Traumatic perieardiophrenic hernia: A report of 3 cases. Br J Surg 1983;70:117-119. 15. Troop B, Myers RM, Agarwal NN: Early recognition of diaphragmatic injuries from blunt trauma. Ann Emerg Med 1985;14:97-101. 16. Fagan CJ, Schreiber MH, Amparo EG, et al: Traumatic diaphragmatic hernia into pericardium: Verification of diagnosis by computed tomography. J Comput Assist Tomogr 1979;3:405-408. 17. Larrieu AJ, Wiener I, Alexander R, et al: Pericardiodiaphragmatic hernia. Am J Surg 1980;139:436-440.

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Delayed presentation of intrapericardial diaphragmatic hernia, an unusual cause of colon obstruction.

The earliest symptoms of diaphragmatic hernia may not appear until viscera incarcerate in it years after the causal injury. The most unusual site for ...
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