Diaphragmatic rupture and hernia

Case contributed by A.Prof Frank Gaillard

Presentation

Motor vehicle accident.

Patient Data

Age: 30 years
Gender: Male
Modality: X-ray

Left sided pneumothorax, lower rib fractures and chest wall / neck subcutaneous emphysema

One month later - abdominal pain and acute renal failure

Modality: X-ray

The expected normal contour of the left hemidiaphragm is not present and the stomach is elevated from its typical location. 

CT abdomen

Modality: CT

Patient went on to have a CT scan. No IV contrast given due to the patient's acute renal impairment. Some oral contrast was passed down the NG tube.

There is a defect in the left hemidiaphragm through which a significant portion of the stomach has herniated.  The herniated portion appears markedly thick walled and there is extensive inflammatory change surrounding it.  In addition no contrast passes through into the distal stomach or duodenum suggesting that there may well be an associated obstructive component.  No definite twist can be demonstrated.  The other intra abdominal organs which are unenhanced appear within normal limits.  There is no free gas.  There is a little fluid around the abnormal stomach.  There is left lower zone consolidation and linear atelectasis with a small left pleural effusion, but the lung bases are otherwise clear.  No bone lesion.

Case Discussion

Delayed presentation of hemidiaphragm rupture following chest trauma is not unusual and emphasizes the importance of evaluating the diaphragm carefully on initial trauma CT scans. This patient went on to have a laparoscopic diaphragmatic repair, and recovered uneventfully. 

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Case Information

rID: 16224
Case created: 31st Dec 2011
Last edited: 10th Nov 2016
Inclusion in quiz mode: Included

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