Delayed presentation of traumatic diaphragmatic hernia

Abstract

A 48-year-old man with no significant past medical history presented to the Emergency Department complaining of 4 days of crampy abdominal pain, with increasing intensity 2 days before arrival and the onset of nausea and vomiting 1 day before arrival. The patient had been afebrile during this time, passing flatus until the day before presentation, but without bowel movement for 4 days. On examination, the patient was noted to have intermittent episodes of significant abdominal discomfort occurring every 3 to 10 min. The patient had mild abdominal distention, no visible abdominal wall scars, active bowel sounds, mild tenderness to palpation of the left upper quadrant, no guarding, rigidity, or rebound. A rectal examination showed heme-negative brown stool. No herniae were palpable, and genitourinary examination was unremarkable. The remainder of the physical examination was unrevealing, with the exception of a small 2 cm scar located at the lower aspect of the patient’s left ribs in the mid-axillary line. On further questioning, the patient recalled a knife injury sustained during an altercation approximately 18 years prior, which was managed non-operatively. A chest X-ray study is shown in Figure 1. A subsequent X-ray study was ordered to obtain further views of the diaphragm and abdomen and is shown in Figure 2. A chest computed tomography (CT) scan showed herniation of the splenic flexure into the chest cavity, with dilatation of the bowel proximal to the diaphragm, and decompression of the bowel distal to the herniation. Figure 3 shows an image from the chest CT scan. Inflammation within the pericolic fat was noted, raising the concern for strangulated diaphragmatic hernia. The patient was taken to the operating room where reduction of the hernia was performed through an abdominal approach. The bowel was found to be viable, with evidence of inflammatory changes involving the herniated omentum. The patient did well post-operatively, and was discharged 5 days after surgical intervention. Delayed presentation of traumatic diaphragmatic hernia (TDH) is an infrequent but well-described condition (1–4). In one series of 111 patients with traumatic diaphragmatic hernia treated over a 5 1/2-year period, 8 patients were first recognized to have a hernia more than 30 days post-injury, with a range of 1 month to 5 years (1); another study reports a 45-year interval between injury and presentation (3). Patients with delayed presentation of traumatic diaphragmatic hernia tend to be male, with histories of either penetrating trauma (stab wounds and gunshot wounds), or blunt trauma (motor vehicle accidents). The left diaphragm may be more susceptible to injury by stabbing, partly because most assailants are right-handed (5). Presenting complaints often include abdominal pain, nausea, vomiting, dyspnea, shoulder pain, or chest pain; however, patients may be asymptomatic at diagnosis.