|Year : 2015 | Volume
| Issue : 2 | Page : 106-108
Traumatic diaphragmatic hernia presenting late with non respiratory symptoms
G Dutta1, R Mondal2
1 Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
2 Department of General Surgery, Radha Gobinda Kar Medical College and Hospital, Kolkata, West Bengal, India
|Date of Web Publication||16-Jun-2015|
Dr. G Dutta
113 Ashutosh Road, Ward No: 1, PO: Mathabhanga, Cooch Behar - 736 146, West Bengal, Kolkata
Source of Support: None, Conflict of Interest: None
A penetrating injury to the chest may cause a diaphragmatic rupture. Presentation can be acute or delayed. Traumatic diaphragmatic hernia (DH) usually presents with symptoms of respiratory compromise. We present a case of a middle-aged man who attended our emergency and diagnosed as acute intestinal obstruction, both clinically and radiologically. A history of stab injury over left chest 10 years back and chest X-ray showed bowel loops in left hemithorax. Diaphragmatic herniation was suspected, although there were no respiratory symptoms on presentation. On laparotomy, a rent of 4 cm × 3 cm was found in the posterolateral aspect of left hemidiaphragm, through which a part of transverse colon and omentum was herniated. The herniated contents were reduced. Closure of the diaphragm followed by loop transverse colostomy was done. The rent was surrounded all around with the ragged diaphragm, which made the possibility of congenital DH unlikely. Thus, a case of traumatic DH was finally diagnosed without respiratory symptoms. With this case we would like to highlight that delayed presentation of traumatic DH may also present with absence of respiratory symptoms.
Keywords: Diaphragmatic hernia, intestinal obstruction, stab injury
|How to cite this article:|
Dutta G, Mondal R. Traumatic diaphragmatic hernia presenting late with non respiratory symptoms. Arch Int Surg 2015;5:106-8
| Introduction|| |
Most of diaphragmatic hernias (DHs) are congenital. The occurrence of traumatic DH is relatively rare, with blunt trauma being commoner than penetrating trauma. Not all diaphragmatic injuries are recognizable at the time of trauma. Many of them recover well and may not have any complication thereafter. However, few of them may present late with persistent respiratory or abdominal symptoms or present in emergency with acute abdomen like, intestinal obstruction and its sequel.  In majority of cases respiratory complaints are associated with abdominal symptoms. Here we report a case of left-sided traumatic DH that presented late as acute abdomen without having respiratory symptoms.
| Case Report|| |
A 30-year-old male presented to our emergency department with severe abdominal pain of diffuse nature and sudden onset, gradual distention of abdomen over 24 h, and obstipation. He had three episodes of feculent vomiting on that day. There was no associated history of hematemesis, fever, or trauma in the recent period. Neither there was any history of respiratory distress, chest pain nor any history of instrumentations or operation. He had a stab injury to the left chest 10 years back, for which he was admitted to a local hospital and was subsequently discharged after primary suturing. On general examination, the patient was dehydrated and pale. Tachypnea and tachycardia was present. His blood pressure was 98/60 mmHg. Air entry was restricted on the left side. Examination revealed distended and shiny abdomen that was tense and tender. It was also tympanatic in all quadrants. On digital rectal examination, the rectum was empty except mucus staining of finger. A 2 cm transverse scar was present in the left mid-axillary line along the seventh intercostals space suggestive of previous stab wound [Figure 1]. A provisional diagnosis of acute intestinal obstruction due to traumatic DH was made. Erect X-ray of abdomen showed multiple air-fluid levels throughout the abdomen and chest X-ray revealed bowel loops in the left hemithorax.
|Figure 1: Scar mark in the mid axillary line at the level of seventh intercostal space shown inside the circle and arrow, to the chest drain site|
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We resuscitated the patient, arranged for blood, and decided to go for an open laparotomy. On laparotomy, serous fluid came out from the abdomen. Small intestine, ascending colon, and right half of transverse colon were distended. Rest of the gut from splenic flexure found collapsed. We traced the gut and a rent of 4 cm × 3 cm found on the left posterolateral aspect of diaphragm, through which left half of transverse colon with omentum entered inside the thoracic cavity [Figure 2]. The omentum was dissected and reduced. Herniated transverse colon was lusterless, congested, and dark suggesting impending gangrene. After putting a hot mop, the congestion was reduced. After reduction of the hernia contents, the edge of the rent was found ragged and surrounded with diaphragm muscle. Presence of congenital DH thus excluded. The diaphragmatic rent was closed with monofilament nonabsorbable polypropylene 3-0 suture [Figure 3] and left a water-sealed intercostal chest tube drain in the plural cavity. Thorough peritoneal lavage was done. Transverse loop colostomy was performed and the abdomen closed in layers over a closed tube drain. Postoperative period was uneventful. It was thus diagnosed finally as a case of intestinal obstruction resulting from sequel of traumatic DH with late presentation. The abdominal and chest drains removed subsequently. Colostomy closure was performed after 8 weeks and the patient is doing well in the follow-up.
|Figure 2: Diaphragmatic rent of 4 cm × 3 cm seen after reduction of hernia contents showing ragged margins all around|
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|Figure 3: Posterolateral diaphragmatic rent closed with interrupted polypropylene sutures|
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| Discussion|| |
Diaphragmatic rupture due to trauma is not rare nowadays, but delayed presentation with a gap of years is of course a rare entity. Approximately 4-6% of patients who undergo surgery for trauma may have associated diaphragmatic injury.  Diaphragmatic injuries are caused either by penetrating or blunt injuries to the abdomen.  Many of them remain undiagnosed and asymptomatic during their entire life. Most of them are diagnosed immediately after the trauma either by imaging or incidentally during the operative procedure when decision for operation is taken for other associated injuries. They may also present late having complaints pertaining to respiration with or without features of acute intestinal obstruction.  Symptoms in decreasing order of severity are chest pain, shortness of breath, and symptoms of large bowel obstruction. The presentation has been described into three phases - the acute phase, latent phase, and obstructive phase.  Patients with obstructive phase often present months to years later with incarceration, obstruction, strangulation, or perforation. Late presentation is mostly due to delayed detection when the patient becomes symptomatic; there is also evidence of delayed rupture in some instances.  In small DH, presentation is late and left-sided herniation is commoner irrespective of the mode of diaphragmatic as the right diaphragm is more protected by the presence of liver. , Commonly herniated organs on the left side are the stomach (80%), omentum, small intestine, colon, and spleen.  Mostly, affected patients are young male. Most of the studies showed that the interval between the injury and the onset of symptoms is about 2 weeks-40 years with an average of 7.3 years. Symbas et al., observed a delay in diagnosis in 8% of cases of diaphragmatic injury from 18 h to 15 years after injury.  High index of suspicion is required in a patient with history of abdominal or chest trauma.  Chest X-ray should be done routinely or after insertion of nasogastric tube. Barium meal is the diagnosis of choice in delayed traumatic DH. Computed tomography (CT)or focused abdominal sonography for trauma (FAST)can also detect DH.
Principle of treatment is immediate operative reduction of herniated viscous and closure of the defect. There are three routes of approach described laparotomy, thoracotomy, thoracolaparotomy. Abdominal approach is commonly done by general surgeons and preferable in left-sided and acute cases with suspected intra-abdominal lesions. , Although use of both nonabsorbable and absorbable suturing materials is described, but nonabsorbable sutures are preferred.  Repair can be done either with interrupted or continuous techniques. Simple suture is enough in smaller defects; larger defects need a synthetic mesh. 
| Conclusion|| |
This case report is presented to illustrate that an acute emergency situation can rise from an occult injury to the diaphragm and DH can also present without respiratory complaints as in this case there was neither chest pain nor respiratory distress. In case of left-sided DH, when presenting with acute abdomen, laparotomy gives fairly good exposure.
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[Figure 1], [Figure 2], [Figure 3]