Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma

Abstract

Rupture of the diaphragm is almost always due to major trauma and is most commonly associated with road-traffic accidents. We report a case of delayed presentation of a 35-year-old woman with a ruptured diaphragm, 11 days following apparent minor blunt trauma. This case illustrates how the diagnosis of ruptured diaphragm can be missed and demonstrates the importance of considering this diagnosis in all cases of blunt trauma to the trunk. It also demonstrates the potential pitfall of misinterpreting the chest radiograph, and the value of repeat imaging after insertion of a nasogastric tube.

Pitfalls in diagnosis of diaphragmatic tear

“…[2] Diaphragmatic injury is a recognize consequence of high velocity blunt and penetrating trauma to the abdomen and chest rather than from a trivial fall. [3] These patients usually have multi system injuries because of the large force required to rupture the diaphragm. [4] Diaphragm is the musculotendinous structure that seals the inferior thoracic aperture.…”

Delayed Presentation of Diaphragmatic Rupture: An Unusual Case of Dyspnea

“…9 Delayed rupture may occur several days after the initial injury as a process of inflammation and necrosis of a devitalized diaphragmatic muscle. 10,11 Small diaphragmatic tears may enlarge over time, allowing herniation of abdominal organs into the thoracic cavity, which may be another explanation for late diagnosis. Finally, in patients receiving mechanical ventilation with PEEP, positive intrathoracic pressure counterpoises intraabdominal pressure, and only extubation precipitates the phenomenon of a diaphragmatic hernia.…”

Late Complication In Patient With Traumatic Diaphragmatic Defect: Internal Hernia

“…Diğer bölgelerde görülme sıklığı; sağ tarafa yerleşim %24,2, bilateral yerleşimli olmak ise %1,5 olarak bulunmuştur (9). Otopsi çalışmalarında sağ veya sola yerleşim oranlarının eşit olduğu saptanırken; antemortem çalışma sonuçlarında, diyafragmatik rüp-türlerin %88-95'inin sol taraf yerleşimli meydana gelmiş olduğu bildirilmektedir (2). Literatürün sistematik olarak gözden geçirilmesinde ise 27 olguda sol; buna karşılık ise 13 olguda sağ yerleşimli diyafragmatik rüptür olduğu bildir ilmektedir (1).…”

“…Diyafragma rüptürünün oluşması için büyük bir gerektiğinden dolayı bu hastalar genellikle çoğul organ hasarlıdır (2). Diyafragma rüptürleri, penetran veya künt torakoabdominal travmaların %0, 6'sı ve tüm vücut travmalarının %4,5-6'sında görülmektedir (3,4).…”