Rare disease Background: Diaphragmatic rupture is a rare pathology that reported in less than 0.5% of all trauma cases, with signs and symptoms that can easily be misdiagnosed. Clinicians must maintain a high index of suspicion to correctly diagnose and manage this pathology. We present a rare case of a large diaphragmatic rupture with transthoracic gastric and colon herniation that was successfully repaired, along with a literature review. Case Report: A 59-year-old woman presented to our Trauma Center after being involved in a motor vehicle collision. She complained of chest and abdominal pain, with decreased breath sounds on the left side. CT imaging revealed discontinuity of the left hemidiaphragm, with intrathoracic herniation of stomach and colon with multiple other injuries. The patient was taken for an emergent laparotomy. The diaphragmatic rupture measured 20 cm in length, with a stellate component. After ensuring complete reduction of the herniated organs, the diaphragmatic defect was primarily repaired. The patient recovered from her injuries and was doing well at last followup in the clinic. Conclusions: This case highlights the importance of diaphragmatic rupture and its associated intra-abdominal injuries when treating trauma patients. With missed diaphragmatic injuries leading to a potential morbidity rate of 30% and mortality rate as high as 10%, the clinician must have a high index of suspicion to correctly diagnose and manage this pathology in a timely fashion. More research is needed to provide surgeons with evidence-based standardized therapies for dealing with these rare pathologies to ensure optimal patient outcomes.
HighlightsIt may be beneficial for patients with type 2 Amyand’s hernia to have an appendectomy with a tension free hernia repair using mesh.Controversies still exist regarding the recognized classification system and treatment algorithm of Amyand hernia.Controversy exists regarding the use of mesh for the treatment of type 2 Amyand’s hernia however we add to the argument of pro-mesh.
BackgroundClinicians must maintain an index of suspicion to diagnose an anorectal foreign body (FB). The patient may not be forthcoming with information secondary to embarrassment or possibly psychiatric issues. Providers must express empathy and compassion while maintaining nonjudgmental composure. Despite accounts of anal FB insertion, this pathology is lacking level one evidence-based surgical algorithms.Case presentationA 46-year-old male psychiatric patient presented in septic shock, complaining of lower abdominal/pelvic pain starting 1 week prior. His past medical history was significant for schizophrenia, bipolar disorder, and noncompliance with medications. CT of the abdomen/pelvis revealed a rectal perforation with free air and a FB which appeared to be a screwdriver. Fluid resuscitation and broad-spectrum antibiotics were administered. In the operating room, after unsuccessful transrectal removal, an exploratory laparotomy was performed. The metallic end of the screwdriver had perforated the rectosigmoid. Resection of the perforated rectum with removal of the screwdriver, incision and drainage of a large right buttock abscess and colostomy was performed. The patient recovered and was discharged to behavioral health. At 2 weeks follow-up the patient was doing well with a functioning colostomy and reversal was planned for later this year.ConclusionThis case highlights the importance of maintaining a high index of suspicion when encountering psychiatric patients with nonspecific lower abdominal or anorectal pain with inconsistent presentations. Controversy exists regarding the type of surgical treatment in case of anorectal perforation. More research is needed to provide surgeons with evidence-based standardized methods for dealing with these rare pathologies.
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