Blunt
injury to the diaphragm occurs in approximately 1% of all trauma admissions.
The diaphragm is most commonly injured by a direct blow to the abdomen,
causing a sudden increase in intra-abdominal pressure, or by direct
laceration from rib fractures. Rupture of the diaphragm rarely occurs
in isolation, and associated injuries to the thoracic aorta, liver
and spleen and pelvis are often present. We present a case of diaphragmatic
hernia who came with unusual aetiology.
Introduction
The diaphragm is a strong partition consisting of a central tendinous
part and a peripheral muscular part. It separates the thoracic cavity
from the abdominal cavity. Injuries to the diaphragm may follow blunt
or penetrating thoraco-abdominal trauma. Blunt trauma accounts for
75-81% of cases.1,2 Road traffic accident is the most common
cause.3 It occurs in 5-25% of thoracic and abdominal blunt
injuries.4,5 The liver, stomach, colon, spleen and greater
omentum are the most commonly herniated organs. Diagnosis represents
a challenge to the surgeon and is often difficult due to lack of specific
clinical and plain radiological features, the frequent presence of
associated injuries of other organs, the difficulty to identify the
injury and the potential for delayed presentation. We present a case
of spontaneous diaphragmatic hernia due to lifting heavy weight.
Case Report
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| Fig.
1 : X-ray chest showing raised left hemidiaphragm. |
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Fig.
2 : X-ray chest showing raised left hemidiaphragm with
stomach in the thorax and collapse of the left lower lobe of lung. |
We present a case
of 55 year old man who presented to our medical registrar with pain
in the left side of chest which started two days back following lifting
heavy weight. Pain gradually increased in intensity and also spread
to left hypochondrium. On admission patient had normal vitals, however,
clinically there was decreased air entry in the left lower zone of
chest. X-ray chest revealed raised left hemidiaphragm with collapse
of the left lower lobe of lung (Fig.1). Patient had no previous history
of trauma to the chest. Patient started having dyspnoea within six
hours of admission and a repeat X-ray chest revealed stomach with
ryles tube in the left thorax which confirmed diaphragmatic hernia
(Fig. 2) . Patient was referred to our surgical unit . In view of
progressive symptoms of the patient, exploratory laparotomy was done.
Intra-operative findings revealed stomach and spleen in the thorax
through a 10 cm X 8 cm defect in the diaphragm. The lower lobe of
the left lung was
collapsed. Stomach and spleen were reposited back in the abdomen and
diaphragmatic defect was closed with prolene mesh after putting an
intercostal drain. Post-operative recovery was uneventful with full
expansion of the left lung. Follow-up of 18 months has shown patient
to be disease free. This presentation of diaphragmatic hernia following
lifting heavy weight is extremely rare.
Discussion
The most common cause of acquired diaphragmatic disorders is by far
trauma, either blunt or penetrating. There are two types of traumatic
diaphragmatic rupture : tension type (indirect) due to distortion
of the bony thorax; and, impact type (direct) that results from blunt
force on the bony thorax.6 The following theories have
been postulated to explain the mechanism of rupture: (1) shearing
of a stretched membrane, (2) avulsion of the diaphragm from its points
of attachment, and (3) sudden force transmission through viscera acting
as a viscous fluid. In our case sudden increase in intra-abdominal
pressure while lifting weight was the cause of presentation.
A history of trauma to the lower chest or abdomen,1 or
the presence of a defect in the contour of the diaphragm on the chest
radiograph,7,8 may suggest diaphragmatic hernia. Chest
roentgenogram was found to be the best diagnostic aid and may show
unilateral elevation of the diaphragm, supradiaphragmatic densities
and displacement of abdominal organs.
Differential diagnoses for elevation of the left hemidiaphragm include:
phrenic nerve palsy, atelectasis, subpulmonic effusion, subpulmonic
abscess, diaphragmatic hernia, eventration of the diaphragm, and distended
abdominal viscera.9
Although the diagnosis of diaphragmatic eventration can be confirmed
in most cases by routine chest radiograph and fluoroscopy, it can
be difficult to differentiate from a diaphragmatic hernia, especially
a hernia “sac.” Induction of a pneumoperitoneum is a safe
and accurate diagnostic procedure for differentiating a diaphragmatic
hernia from a paralyzed or eventrated diaphragm. In diaphragmatic
hernia, the injected air will enter from the peritoneum into the pleural
cavity.10 Sonography, radionuclide liver and spleen scanning,11
and CT of the chest12 may be necessary for diagnosis of
hernia in occasional cases.
All acute injuries must be repaired surgically either conventionally
or by minimal access surgery in order to avoid the long term consequences
of herniation including intestinal obstruction, perforation, strangulation
or even thoracic complications. Classically, delayed cases are approached
through the thorax because of the presence of adhesions between abdominal
viscera and thoracic structures.
In conclusion, traumatic diaphragmatic rupture is a serious surgical
problem with high mortality due to the associated injury. A high index
of suspicion is essential. All acute cases whether diagnosed pre-operatively
or intraoperatively must be repaired surgically either by laparotomy,
thoracotomy, thoraco-abdominal approach or by minimal access surgery,
in order to avoid the long-term sequaele.
Acknowledgement
We would like to thank Dean and Dr.G.B.Daver Head of the Department
of Surgery, Grant Medical College and JJ Group of Hospitals for granting
us permission to publish this case report.
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The most advanced clinically tested agents that increase the
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an exciting new approach to the treatment of high-risk patients
with cardiovascular disease. The combined use of statins and
CETP inhibitors has the potential for markedly improving our
effectiveness in reducing the risk of cardiac events in patients
with cardiovascular disease.
H Bryan Brewer, N Engl J Med 2004; 350 (15) : 1491-94. |
