A Fiendish Finding

aka Trauma Tribulation 004

A 21 year-old female presents with acute onset of unrelenting abdominal pain and vomiting four years after a major motor vehicle accident.  A chest X-ray is performed:

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Questions

Q1. What is the likely diagnosis?

Traumatic rupture of the diaphragm with strangulation of viscera in the chest.

Ambroise Paré, in 1579, described the first case of diaphragmatic rupture diagnosed at autopsy. The patient was a French artillery captain who initially survived a gunshot wound of the abdomen, but died 8 months later of a strangulated gangrenous colon, herniated through a small diaphragmatic defect that would admit only the tip of the small finger.

Q2. How could this complication have been prevented?

The only answer I can think of to this question is to have made the diagnosis earlier and repaired the diaphragm!  However, traumatic rupture of the diaphragm is a difficult diagnosis to make.   A high index of suspicion is required.

Pathognomonic chest X-ray findings include:

  • the presence of bowel or stomach gas in the chest
  • a nasogastric tube that passes through or finishes in the chest

Suggestive chest X-ray findings include:

  • Irregularity of the diaphragmatic outline
  • an elevated hemidiaphragm
  • Mediastinal shift without pulmonary or intrapleural cause

Q3.  How is this condition treated?

Treatment requires surgical repair of the diaphragm.

In this case, resection of strangulated viscera may be required.  Laparotomy is the preferred approach in acute cases because it allows for treatment of associated abdominal injuries while thoracotomy is the best approach in chronic cases.

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