Incarcerated diaphragmatic hernia with large bowel obstruction

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

This patient presented to the ED with 3 days of abdominal distension and vomiting. There is a remote history of laparotomy after getting stabbed.

Patient Data

Age: 25 years old
Gender: Male

Preliminary plain radiographs

Modality: X-ray

There is a left diaphragmatic hernia that contains a gas-filled viscus with an air-fluid level.

The right and transverse colon, and smal bowel are abnormally dilated. There is no gas in the rectum or left colon.

The transverse and right colon, and ileum are grossly distended. The cecum measures more than 10cm in diameter on sagittal images. The left colon and rectum are collapsed. There is a transition point at a left diaphragmatic hernia (ostium 2cm). The hernia contains a short segment of the splenic flexure that is distended with gas and fluid. The colon is thin-walled and there is no evidence or ischaemia/strangulation. There is some free intraperitoneal fluid, but no free intraperitoneal gas.

Case Discussion

The remote history of stab wound to the abdomen suggests that the diaphragmatic hernia in this case is a traumatic one, rather than a congenital. In fact, most case reports of incarcerated diaphragmatic hernia with large bowel obstruction describe prior trauma in one form or another, in some cases many years ago.

The obstruction was deemed high-grade. The cecum measures almost 11cm, despite an incompetent ileocecal valve, which is considered high risk for perforation.

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Case Information

rID: 22191
Case created: 18th Mar 2013
Last edited: 19th Feb 2016
Inclusion in quiz mode: Included

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