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
Preliminary plain radiographs
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There is a left diaphragmatic hernia that contains a gas-filled viscus with an air-fluid level.
The right and transverse colon, and small bowel are abnormally dilated. There is no gas in the rectum or left colon.
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The transverse and right colon, and ileum are grossly distended. The cecum measures more than 10 cm in diameter on sagittal images. The left colon and rectum are collapsed. There is a transition point at a left diaphragmatic hernia (ostium 2 cm). 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 ischemia/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 11 cm, despite an incompetent ileocecal valve, which is considered high risk for perforation.
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