Delayed Diaphragmatic Herniation Masquerading as a Complicated Parapneumonic Effusion

Abstract

Injury to the diaphragm following blunt or penetrating thoracoabdominal trauma is not uncommon. Recognition of this important complication of trauma continues to be a challenge because of the lack of specific clinical and plain radiographic features, the frequent presence of other serious injuries and the potential for delayed presentation. Delayed diaphragmatic herniation often presents with catastrophic bowel obstruction or strangulation. Early recognition of diaphragmatic injury is required to avoid this potentially lethal complication. The case of a 35-year-old man with a history of a knife wound to the left flank 15 years previously, who presented with unexplained acute hypoxemic respiratory failure and a unilateral exudative pleural effusion that was refractory to tube thoracostomy drainage, is reported. After admission to hospital, he developed gross dilation of his colon; emergency laparotomy revealed an incarcerated colonic herniation into the left hemithorax. Interesting clinical features of this patient's case included the patient's hobby of weightlifting, a persistently deviated mediastinum despite drainage of the pleural effusion and deceptive pleural fluid biochemical indices. Key Words: Acute ileus; Bowel obstruction; Deviated mediastinum; Pleural effusion; WeightliftingConfusion entre épanchement parapneumonique compliqué et hernie diaphragmatique tardive RÉSUMÉ : L'atteinte diaphragmatique n'est pas rare après un traumatisme thoraco-abdominal fermé ou pénétrant. La reconnaissance de cette importante complication des traumatismes continue de représenter un défi, compte tenu de l'absence de caractéristiques spécifiques sur les plans des symptômes cliniques et des clichés radiologiques simples, de la présence fréquente d'autres lésions graves et du risque que les manifestations apparaissent tardivement. L'hernie diaphragmatique tardive s'accompagne souvent d'une dangereuse obstruction ou strangulation intestinale. Le diagnostic précoce de cette lésion diaphragmatique est nécessaire pour éviter une complication potentiellement fatale. Le cas présenté ici est celui d'un homme de 35 ans ayant subi 15 ans auparavant une blessure à l'arme blanche au côté gauche; il se présente pour insuffisance respiratoire hypoxémique aiguë inexpliquée et épanchement pleural exsudatif bilatéral réfractaire au traitement par thoracotomie. Après son admission à l'hôpital, il a présenté une dilatation marquée du côlon. La laparotomie d'urgence a révélé une hernie irréductible du côlon dans l'hémithorax gauche. Parmi les caractéristiques intéressantes de ce cas, mentionnons le passetemps du patient, haltérophile, un médiastin présentant une déviation persistante malgré le drainage de l'épanchement pleural et les indices biochimiques trompeurs du liquide pleural.T raumatic injury and subsequent herniation through the diaphragm was first described over 400 years ago (1), and the first successful repair was reported in 1886 (2). Correct diagnosis of this potentially lethal condition continues to require a high index of suspic...

Complications of Percutaneous Fluid Drainage

“…16 In addition, mimickers of empyema such as diaphragmatic herniation of enteric structures should be excluded before catheter placement. 17 Mediastinal abscesses usually result from cardiothoracic surgery and are typically covered by lung tissue or in close proximity to major vascular structures. The authors recommend the Seldinger technique under CT guidance, with the addition of Doppler US guidance if necessary.…”

Bilious vomiting in a 6‐month‐old infant

“…Associations have been identified with sepsis and obstructive jaundice, 7 group B streptococcal infection 8 and failure to thrive 10 . However, the lack of unique symptoms for late‐onset CDH is reflected in the differential diagnoses, which include aspiration syndromes, bronchogenic cysts, pneumonia, pleural effusions, pneumothorax and persistent newborn pulmonary hyper­tension 1,11−13 …”

“…10 However, the lack of unique symptoms for late-onset CDH is reflected in the differential diagnoses, which include aspiration syndromes, bronchogenic cysts, pneumonia, pleural effusions, pneumothorax and persistent newborn pulmonary hypertension. 1,[11][12][13] Examination of patients with CDH might be expected to produce signs including a displaced cardiac apex beat, decreased breath sounds on the ipsilateral side, scaphoid abdomen and auscultation of bowel sounds in the thorax. 14 Cystic lesions or masses in the lower lung fields should also suggest the possibility of CDH with herniated abdominal contents at any age.…”

“…Similarly, as in the present case, delayed diaphragmatic hernias could be associated with normal previous chest radiographs. 2,12,14,15 Postnatal radiological findings vary greatly from one case to another and even within the same case at different times because of differences in herniated organs and intermittent spontaneous reduction. [12][13][14] Thus, a previously normal chest radiograph does not preclude a diagnosis of a CDH.…”

“…2,12,14,15 Postnatal radiological findings vary greatly from one case to another and even within the same case at different times because of differences in herniated organs and intermittent spontaneous reduction. [12][13][14] Thus, a previously normal chest radiograph does not preclude a diagnosis of a CDH. In the patient in the present case report, we speculate that the preceding coughing illness for which her general practitioner prescribed oral antibiotics might have been the catalyst for the herniation of the gastrointestinal contents into the left hemithorax.…”