Traumatic intrapericardial diaphragmatic hernia: findings on a computed tomography scan

Abstract

Traumatic intrapericardial diaphragmatic hernia is the rarest type of diaphragmatic hernia, occurring in less than 1% of cases of diaphragmatic ruptures. 1 Less than 100 cases have been reported, or approximately one case is reported every year. 2 The diagnosis can be often delayed because of its rarity and a nonspecific simple chest X-ray finding. We herein report a case of traumatic intrapericardial diaphragmatic hernia which was accompanied by elevated ST segments on the electrocardiogram (EKG).A 43-year-old man encountered a traffic accident while he was driving an automobile in October 2013. His left chest and arm were pinned to the crushed door of the automobile. His chief complaints were orthopnea and epigastric discomfort which were difficult to explain. His vital signs were as follows: blood pressure of 110/ 70 mm Hg, pulse rate of 82 beats/min and respiratory rate of 19 breaths/min. A chest X-ray showed non-specific finding (Fig. 1). A diaphragmatic rupture with herniation of stomach into the left pleural cavity was initially suspected on computed tomography (CT) scans. Intrapericardial diaphragmatic hernia was not recognized preoperatively in spite of suggestive findings on CT scans (Fig. 2). An initial EKG showed elevated ST segments, between the QRS complex and the T wave, on the precordial leads ( Fig. 3) even though the levels of cardiac enzymes were normal. The patient was immediately taken to the operating room for exploration with left thoracoscopy. No herniated viscera were found in the pleura. We opened pericardium because it was slightly bulging and found herniated omental tissues and 8 cm transverse ruptured diaphragm. Initially, we tried to let the herniated tissue down and repair the diaphragm, but it was difficult due to narrow working space via thoracoscopy. So, we added additional upper laparotomy on the epigastrium. Herniated omentum and stomach were pulled down to peritoneum and the ruptured diaphragm was repaired with multiple interrupted 1-0 polypropylene sutures. The patient's haemodynamic status was stable after surgery. Initial ST-segment elevation in EKG also resolved. He recovered and was subsequently discharged home.Traumatic intrapericardial diaphragmatic hernia occurs from pericardio-diaphragmatic rupture because the pericardium is attached to the central part of the diaphragm.The symptoms and signs are various. According to the literature review, 2 respiratory, abdominal and cardiac symptoms and signs are the most common. Cardiac tamponade is rare but critical. 2,3 Our patient complained orthopnea and epigastric discomfort which were difficult to explain. The diagnosis is often delayed because of ambiguous or non-specific symptoms and signs. 3 Initial chest X-ray is not diagnostic of the whole diaphragmatic rupture more than 50%. 4 Furthermore, it is more difficult to find abnormal finding in case of an intrapericardial diaphragmatic rupture. Changes of EKG can be clinical manifestations. Barrett et al. 5 reported the changes of EKG typically seen in acute pericarditis: u...