Case Report
Report of Rare Emergency Presentations and Management of Delay Diaphragmatic Hernia in Five Cases
Amir Hassankhani1*, Alireza Amir Maafi1, Yasman Safarpoor1, Manouchehr Aghajanzadeh2,
Mohammad Sadegh Esmaeili Delshad2, Tina Mehrpey Moghaddam2 and Elahe Rafiei2
1Guilan University of Medical Sciences, Rasht, Iran
2Department of Internal Medicine, Inflammatory Lung Disease Research Center, Razi Hospital, School of Medicine,
Guilan University of Medical Sciences, Rasht, Iran
*Corresponding author: Amir Hassankhani, Student Research Center Office, Research Deputy Building of Guilan University of Medical Sciences, Rasht, Iran
Published: 25 May, 2017
Cite this article as: Hassankhani A, Maafi AA, Safarpoor
Y, Aghajanzadeh M, Delshad MSE,
Moghaddam TM, et al. Report of
Rare Emergency Presentations and
Management of Delay Diaphragmatic
Hernia in Five Cases. Clin Surg. 2017;
2: 1480.
Abstract
Diaphragmatic Ruptures (DR) is a life-threatening condition. (DR) are quite uncommon and often
result from either blunt or penetrating trauma. (DR) are usually associated with abdominal trauma
however, it can occur in isolation. Acute traumatic rupture of the diaphragm may go unnoticed
and there is often a delay between the injury and the diagnosis. Tension Gastro Thorax (GT), Colo
Thorax (CT) and Hepato Thorax (HT) is a life-threatening condition and presents dramatically
with acute and severe respiratory distress. It develops when an intrathoracic herniation of stomach,
liver or colon through a diaphragmatic defect. Massively distended stomach and colon by trapped
air or fluid causing mediastinal displacement. Tension GT, CT and HT is often missed as tension
pneumothorax and managed as such leading to increased morbidity and mortality. Immediate
clinical and radiographic evaluation should lead to accurate diagnosis followed by emergency
decompression of the stomach, colon and liver. Reduction of herniated viscera must be done before
laparotomy and repair of the diaphragmatic defect. We present five cases with tension (GT), (CT)
and (HT). We performed transthoracic decompress of stomach and colon in three case with chest
tube insertion because other methods were not successful for decompressions and emergency
laparotomy. In two cases right side emergency thoracotomy was performed. Because of this unusual
condition, tension (GT), (CT) and (HT) has not been well characterized in traumatic diaphragmatic
hernia in the literature reviews.
Keywords: Tension gastrothorax; Colothorax; Hepatothorax; Laparotomy; thoracotomy;
Diaphragmatic hernia
Introduction
Late presentation of diaphragmatic rupture is often a result of herniation of abdominal contents into the thorax [1]. Sudden increase in the intra abdominal pressure may cause a diaphragmatic tear and visceral herniation [2]. The incidence of (DR) after thoraco-abdominal traumas is 0.8%-5%, moreover up to 30% of diaphragmatic hernias present with delay [3]. Incorrect interpretation of the X-ray or only intermittent hernia symptoms are frequent reasons for incorrect diagnosis [4]. Traumatic diaphragmatic hernia is a frequently missed diagnosis and there is commonly a delay between trauma and diagnosis [3,4]. The obstruction phase signifies complication of a long standing herniation, manifesting as obstruction, strangulation and perforation [5]. The systematic review of the literature suggests, the mean duration time was, on Day 9 [6], to 50 years [7]. Respiratory distress was the most presenting feature [1,8,9]. Abdominal pain was the next presenting feature [6,10]. The other presentations was intestinal obstruction [5,8,9], tension faeco-pneumothorax [6,8,11] and hematemesis and melena [12]. Tension gastrothorax, colothorax and Hepatothorax present dramatically with acute and severe respiratory distress and cardiac arrest [1,8,9]. It develops when the stomach colon or liver herniated through a left or right sided diaphragmatic defect into the thorax and massively distended by trapped air or fluid [5,6,8,11]. This article focuses on symptoms, diagnosis and treatment of these life-threatening conditions in five cases based on a case report and review of the literature.
Case Presentation
Case 1
A 24-year-old female patient referred to pulmonary medicine outpatient department with right sided chest pain, dyspnea and nonproductive cough for ten days.
She had a past history of a minor trauma. She continued his daily
activities. She was afebrile but dyspneic. Her respiratory rate was 26
breaths/min, oxygen saturation 96% with room air, pulse rate 98/min,
and blood pressure 12/7 mmHg. On examination of the chest, there
was dull note over right infraclavicular area. Examination of other
systems was within normal limits. His chest X-ray posteroanterior
(PA) view revealed a heterogeneous opacity in right lower zone
she was admitted in the chest clinic. Ultrasonography of abdomen
revealed empty of right upper quadrant and liver position was vertical
and was in the upper portion of pleural space. Computed tomography
scan of thorax showed presence of liver, omentum, small intestine and
colon in the right hemi-thorax (Figure 1 and 2). She was diagnosed
to have traumatic right side (DR) with herniation of liver, omentum,
small intestine, colon and liver, which was rotated vertically and
changed its position and shift to the left side of hemithorax and
compressed heart and left lung. During the procedure symptoms of
patient worsened while she was in emergency room, respiratory rate
was 38 breaths/min, oxygen saturation 76% with nasal O2, pulse rate
110/min, and blood pressure 9/6 mm Hg. Patient was intubated and
referred to operation room for emergency operation. Right anterolateral
thoracotomy was performed immediately. There was a large
defect of the diaphragm. About two-third of central portion of
diaphragm was absence, through this defect, liver ,omentum, small
intestine and colon herniated to the tope point of right pleural space.
The herniated organs were reduced to abdomen cavity with difficulty.
The diaphragma was replaced totally with prolene mesh and fixed to
rib with prolene stitch (Figure 3). An intercostal drain was placed
in the left pleura. She made an uneventful recovery. 1n five month
follow-up the conditions of patient were well.
Case 2
A 65-year-old man patient presented to pulmonary medicine
outpatient department with right sided sever chest pain, right upper
quadrant pain, dyspnea and productive cough for 15 days. The
symptoms present after a severe physical activity. Respiratory rate
was 32 breaths/min, oxygen saturation 96% with room air, pulse rate
98/min, and blood pressure 12/7 mmHg. On examination, abdomen
was tender, especially in right upper quadrant and the chest; there
was decreased breath sound on the right chest. Examination of
other systems was within normal limits. Her chest X-ray PA view
revealed a heterogeneous opacity in right lower zone (Figure 4). In
past medical history he had a sever car accident six years ago without
any surgery. He was admitted in the chest clinic. Ultrasonography
of abdomen revealed, right upper quadrant was empty of liver, the
liver position was vertical and was in the upper portion of pleural
space. Computed tomography scan of thorax showed presence of
liver, omentum, and colon with fecal material in the lumen of the
colon in the right hemi-thorax (Figure 5 and 6). He was diagnosed
to have traumatic right side diaphragmatic rupture with herniation
of liver, omentum, and colon. Liver was rotated vertically and the
liver position was changed and shifts to the left side of hemithorax,
compressed the heart and left lung. Four hour after admission and
during work-up, symptoms of patient worsened while he was taken
up in emergency room, respiratory rate was 38 breaths/min, oxygen
saturation 76% with nasal O2, pulse rate 110/min, and blood pressure
of 90/60 mmHg. Patient was intubated and referred to operation
room for emergency surgery of tension hepatic-chylothorax. A right
antero-lateral thoracotomy was performed immediately. There was
a large defect of the diaphragm. About 80% portion of diaphragm
was absence, through this large defect, liver, omentum and colon was
herniated to right pleural space. The liver was rotated to the upper
portion of pleural space. Lung was collapsed. After releases of bands,
the herniated organs were reduced to abdomen cavity. Position of
liver was corrected partially and reduced to the abdominal cavity with difficulty. The diaphragma was replaced totally with prolene
mesh and the edge of mesh fixed to rib with prolene stitch (Figure
7). An intercostal drain was placed in the right pleura space. Post
operation, right lower lobe was atelectatic due to plugs and improved
with bronchoscopy. 1n one year follow-up the conditions of patient
were well.
Case 3
A 25-year-old man referred to our unit with 2 days history of
progressive left sided chest pain, epigastric pain, and dyspnea in
the mountain for army patrol. There was no other positive history
other than a penetrating truma of left hemithorax 2 years ago during
an army training without hemopneumothorax. On examination
he had respiratory distress. Her pulse rate was 98/min and regular,
blood pressure was 90/60 mmHg and respiratory rate was 32/min.
Examination of the chest revealed a decreased air entry in the left
side, which was dull in percussion. There was a shift of mediastinum
to the right side. The epigastrium and left hypochondrium were
tender. The haematological and biochemical parameters were
within normal limits. The chest X-ray revealed a large air fluid level
in the left hemithorax (Figure 8). An ultrasonogram of the chest
and abdomen was performed which showed a large collection of
fluid in the hemithorax but was inconclusive as to whether it was
supra diaphragmatic or infra diaphragmatic. A CT-scan of chest
was performed, there was a massive hydropneumothorax (Figure
9). A clinical and imaging suspicion of hydropneumothorax was
entertained and a chest tube was placed which was no significant
drainage and clinical situations of patient was not improved.
During the procedure her symptoms of obstruction worsened
while she was taken up for emergency surgery. In emergency room
with needle multiple aspirations was performed, a large amount of
air and greenish fluid was aspirated. Evacuation of air and 600 ml of
gastric content, led to immediate relief of symptoms. Antero-lateral
thoracotomy was performed immediately. There was a 7 cm linear
tear in the left dome of the diaphragm which the stomach, greater
omentum, a part of transverse colon had herniated into the left
pleural space. The herniated organs were reduced to abdomen. The
diaphragmatic tear was repaired with prolene mattress sutures. An
intercostal drain was placed in the left pleura. He made an uneventful
recovery except for left lower atelectasis, which was treated with chest
physiotherapy.
Case 4
A previously healthy 19-year-old girl presented to the emergency
department with a 6 hours history of severe abdominal pain, left
chest pain and increasing respiratory distress. Her respiratory rate
was 36/min and heart rate was 110/min, auscultation of lung fields
revealed diminished breath sound over the left side. This patient had
a history of left side chest knife injury and tube thoracostomy was
performed for hemothorax two years ago. A chest and abdominal
X-ray showed a large air-fluid level in the left hemithorax with airfluid
level and shift of the mediastinum to the right side which was
interpreted as tension gastrothorax and colothorax (Figure 10 and
11). Prompt insertion of a nasogastric tube was not possible. A chest
CT scan was preformed and showed a massive hydropneumothorax
in the left hemithorax with septations (Figure 12 and13). During the
procedure her symptoms of obstruction worsened while she was taken up for emergency room, a chest-tube insert in left pleural space
and 1800 cc mall odorous fluid with air exit after this procedure.
On the same day, the patient underwent left-lateral thoracotomy.
Stomach was collapsed and a 4 cm perforation was found in the
body of stomach and transvers colon was gangrenous and multiple
perforations were presented. Thoracotomy incision extended to the
abdomen (thoracoabdominal). Transverse colon was resected and
double barrel colostomy was performed. Perforation of stomach was
repaired. An 8 cm × 6 cm defect was present in the central portion
of left diaphragm. The diaphragmatic tear was repaired with prolene
interrupted sutures. An intercostal drain was placed in the left pleura.
The postoperative course was uneventful and she was discharged
home 7 days after surgery. The colostomy was revised 8 weeks later.
Case 5
A 16-year-old girl presented to our unit with 4 days history of
progressive left sided chest pain and dyspnea. In past history there
was no positive history of trauma and no other chest diseases. On
examination she was distressed and had chest pain. Her pulse
rate was 110 p/mi regular, blood pressure was 100/70 mmHg and
respiratory rate was 38/min. Examination of the chest revealed a
decreased air entry in the left side, which was dull in percussion.
The epigastrium and left hypochondrium were tender. The
haematological and biochemical parameters were within normal
limits. The chest X-ray revealed a large air fluid level in the left
hemithorax and there was a shift of mediastinum to the right side
(Figure 14). A clinical suspicion of diaphragmatic hernia or massive
hydropneumothorax was entertained and a nasogastric tube was
placed with no significant aspiration. An ultrasonogram of the
chest and abdomen was performed which showed a large collection
of fluid in the hemithorax. A chest CT scan was preformed and
showed a massive hydropneumothorax in the left hemithorax and
a shift of mediastinum to the right side (Figure 15 and 16). During
the procedure, her symptoms of obstruction worsened while she
was taken up for emergency surgery. The patient had cardiac arrest
as she entered the anaesthetic room. She was intubated and a chest
tube insert in left pleural space and 2000 cc greenish fluid with air
exit after this procedure. O2 saturation was 92% and the patient’s vital
signs improved immediately. Patient referred to ICU department.
After partially stabilization of cardiovascular conditions, Laparotomy
was performed immediately. There was an 8 cm linear tear in the
left-lateral side of the diaphragm through which the stomach and
greater omentum had herniated into the left chest. The stomach
was back down to the abdomen. A 6 cm perforation was seen on
the greater curvature of stomach, the perforation was repaired.
The diaphragmatic rupture was repaired with prolene interrupted
sutures. Anintercostal drain was placed in the left pleura space. She
referred to the intensive care unit, 6 h after surgery, patient present
with symptoms and a sign of re-expansion pulmonary edema, this
complication was treated with one lung ventilation, hydrocortisone
fluid restriction and diuretic. She discharged with good conditions 6
day postoperation.
Figure 1 and 2
Figure 1 and 2
CT-scan of patient show herniation of liver, omentum, colon
and intestine in pleural space.
Figure 3
Figure 4
Figure 5 and 6
Figure 5 and 6
CT-scan show herniated and vertically position of liver with
displacement of mediastinum and heart, and show omentum and colon.
Figure 7
Figure 8
Figure 9
Figure 9
CT-scan of chest show large air fluid level with sever shift of
mediasinum and collapse of left and right lung.
Figure 10 and 11
Figure 10 and 11
Left side opacification and air-fluid level, multiple air-fluid
level with suspicious of intestinal obstruction.
Figure 12 and 13
Figure 14
Figure 15 and 16
Discussion
Diaphragmatic rupture is a rare complication of trauma,
reported in 1-7% of major blunt trauma patients and 10-15% of
penetrating trauma [1,2,6,13]. Tension gastrothorax is a distended
intrathoracic stomach witch herniated through a congenital or
acquired diaphragmatic defect to the pleural space. Gastric distension
in the pleural space can compress the lung and mediastinal shifting.
This condition is life threatening [4,5,7,14]. Horst, described
pathophysiology events which leading to tension gastrothorax
[9,5]. The cause of herniation is increased, abdominal pressure and
stomach was herniates through a preexisting defect in the diaphragm.
Then tension gastrothorax may occur at any time when the stomach
suddenly fills with air, fluid or food through a one-way valve
mechanism created by abnormal angulation of the gastroesophageal
junction combined with gastric outlet obstruction caused at the
level of the diaphragm [4,5,8,14]. Two of our patients had a heavy
exercise and another one had army effort in the mountain with past
history of blunt and penetrating truma. The clinical picture of (TGT)
is acute respiratory distress, chest wall and epigastric pain, reduced
or absent breath sounds in the left hemithorax and shifting the heart
bit to the right side. This condition commonly been mistaken for a
tension pneumothorax and managed as such leading to increased
morbidity and mortality [4,5,8]. As three of our patients which first
diagnosis was (TGT) or tension bulla. After patient’s conditions
become stable, chest x-ray is first tool for differentiating between the
above mentioned diagnoses. In the (TGT) the chest x-ray findings
are: 1- a large air-filled structure with or without a fluid level in the
left hemithorax. 2- A superior rim formed by compressed left lung
and stomach wall. 3- There is not a stomach bubble in the left upper
quadrant. 4- The left hemidiaphragm shadow will be poorly defined.5- Shifting mediastinum to the right [1,3,8,10]. As our patients
had all above mentions. But in left-sided tension pneumothorax,
the entire left lung is compressed and all lung surrounded by
intrapleural air, hemidiaphragm depressed and ill-defined [1-6].
First step in the management of tension gastrothorax is immediate
placement of a large naso or orogastric tube to decompress the
dilated stomach [4,5,11,14,15]. If this maneuver fails, transthoracic
needle decompression of the stomach recommended [4,5,14]. If this
maneuver fails too we recommended chest-tube insertion. In two of
our patients, this maneuver improved the clinical situations. Positive
pressure ventilation allows immediate re-expansion of the lung and forces intrapleural contents back into the abdomen [14]. We did this
maneuver in one of our patients but were not improved clinical state
of patient. Instant clinical improvement should occur after stomach
decompression [6,10]. If deflation of the stomach is not occur, the
mediastinal shift can impaire venous return and lead to cardiac arrest
[4,5,11,14].
Definitive management after initial resuscitation in these
emergency conditions, with thoracotomy or laparotomy is the access
of choice, but we performed thoacotomy and thoracoabdominal
approach in our patients. Tension colothorax causing sever shifting
of mediastinum, collapse of the underlying lung and cardiac
compression, it is a surgical emergency. It is more common on the
left side and the colon is most likely to herniated [16]. It can be
asymptomatic or present with abdominal pain, intestinal obstruction
and cardio-respiratory distress [16], one of our patients was presented
with tension gastro-chylothorax.
Right side (DR) are rare and difficult to diagnose, as chest
radiography often does not show any specific signs may show only
elevation of the right diaphragmatic border. Right-sided ruptures are
associated with high mortality and morbidity [6,8,13]. Right-sided
(DR) (DR) and subsequent herniation of viscera are uncommon, and
is associated with a higher morbidity and mortality than left-sided
hernias. There are three phases used to describe the presentation of
traumatic (DR): acute, latent, and obstructive phases [12]. The acute
phase occurs during the recovery time from the initial injury. This is
when most diaphragmatic injuries are missed, often due to masking
from other severe, co-existing injuries [1,2,6,13]. The diagnosis may
also be delayed in patients. The latent phase refers to an asymptomatic
period, where herniations are found incidentally on radiologic
imaging performed for other reasons. During the obstructive
phase, Patients are symptomatic often from GI obstruction or
perforation and cardiovascular compromise secondary to herniation
of abdominal contents into the thorax due to sever physical activity
[3,6,7,15]. Two of our patients presented with sever dyspnea, chest
wall and abdominal pain after physical activity with herniation of
colon and liver, who presented 4 to 8 years after the initial trauma.
Accordingly, delayed diagnosis is common in right-sided ruptures,
often resulting in severe complications, such as strangulation ileus
and intrathoracic herniation of the hollow organs (stomach, colon,
and small bowel) [17,18]. Cases of right (DR) with hepatothorax may
result in severe atelectasis of the right lung or tension mediastinum,
thereby severely impeding respiration and circulation [3,6,13]. As our
cases with colon and hepatothorax in such condition an abdominal
and chest CT should be performed quickly, and surgical repair via
a trans-thoracic or trans-abdominal approach should be considered
immediately following radiographic confirmation [3,6,13,17,18]. We
used thoracotomy approach. Because the size of the defect is often too
large a primary repair not possible and prosthetic mesh may prove
necessary. As our two cases, which defect was very large and we used
total prolen mesh for repair of total defect of diaphragm without
complications.
Conclusion
With advances in diagnostic radiology, traumatic diaphragmatic hernia may be diagnosed with late. To avoid these complications, follow-up radiology after the injury may can early detection and, consequently, facilitates timely repair. Tension viscerothorax, which mimic many features of tension pneumothorax, as (tension gastrothorax, colothorax and hepato thorax). If successful, initial decompression of the stomach through a nasogastric, orogastric tube, needle decompression or chest tube insertion in critical condition as tension pneumothorax will improve the emergency situation and definitive repair of the diaphragm defect may be possible.
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