Delayed presentation of traumatic diaphragmatic hernia

Abstract

A 10-year-old boy presented with abdominal pain around the umbilicus since 8 hours, 4 episodes of non-bilious vomiting and pain in the left shoulder since 5 hours. There was no history of fever or bowel disturbances. On examination his general condition was stable. Per abdomen examination revealed tenderness around the umbilicus. Examination of other systems was unremarkable. He had history of chest trauma 7 months back. At that time examination revealed wound measuring 4×2 cm below and lateral to left nipple with normal vitals. Respiratory and abdominal examination was unremarkable. Chest X-ray, sonography and CT scan were normal. Debridement and suture of the wound was done and child discharged after 5 days.During the second admission, his blood counts, urine examination, serum amylase, kidney function test and liver enzymes were within normal limits. Chest X-ray revealed nonvisualization of left diaphragm and presence of distended bowel loops. CT scan showed disrupted left hemidiaphragm with herniation of bowel loops (Fig.1). On laparoscopy, left diaphragm opening was noticed with colon and omentum as contents. Surgeon tried to pull the contents back to abdomen but could not. Therefore laparotomy was performed, contents were reduced (colon was healthy) and closure of diaphram opening was done. Child was discharged after 5 days.