Diaphragmatic rupture causing repeated vomiting in a combined abdominal and head injury patient: a case report and review of the literature
© Symeonidis et al.; licensee BioMed Central Ltd. 2012
Received: 19 March 2012
Accepted: 2 July 2012
Published: 2 July 2012
Diaphragmatic rupture after blunt abdominal injury is a rare trauma condition. Delayed diagnosis is not uncommon especially in the emergency room setting. Associated injuries often shift diagnosis and treatment priorities towards other more life-threatening conditions.
We present a challenging case of a young male with combined abdominal and head trauma. Repeated episodes of vomiting dominated on clinical presentation that in the presence of a deep scalp laceration and facial bruising shifted differential diagnosis towards a traumatic brain injury. However, a computed tomography scan of the brain ruled out any intracranial pathology. Finally, a more meticulous investigation with additional imaging studies confirmed the presence of diaphragmatic rupture that justified the clinical symptoms.
The combination of diaphragmatic rupture with head injury creates a challenging trauma scenario. Increased level of suspicion is essential in order to diagnose timely diaphragmatic rupture in multiple trauma patients.
Diaphragmatic rupture (DR) after blunt abdominal trauma is a rare condition usually masked by multiple associated injuries [1, 2]. The overall incidence of diaphragmatic injury is 2.5 - 5% in blunt abdominal trauma and 1.5% in blunt thoracic trauma . Left sided injuries are substantially more frequent [1, 2]. However, bilateral injuries have also been reported . Delayed diagnosis is not uncommon especially in the emergency room (ER) setting. Despite improvement in investigative techniques a significant amount of these injuries are overlooked. Associated injuries often shift diagnosis and treatment priorities towards other more life-threatening conditions.
However, constant clinical surveillance and repeated evaluations of the patient are of paramount importance in order to minimize the likelihood of missing injuries with non-typical clinical presentation such as DR. Non-specific symptoms emanating from the respiratory system i.e. dyspnea often are the only clues for the diagnosis . On the other hand, strangulation and perforation represent the final devastating consequences of the prolonged herniation of the abdominal organs into the chest . Sometimes, a displaced nasogastric tube within the left hemi thorax, a diagnostic sign in chest x-ray, establishes the diagnosis of DR in asymptomatic trauma patients [3, 4]. In the present report, we present a challenging case of a combined abdominal and head trauma patient. Repeated episodes of vomiting dominated on clinical presentation that on the absence of other clues shifted differential diagnosis towards a traumatic brain injury. However, a DR was finally diagnosed that justified the clinical symptoms.
A 32-year-old, unrestrained male driver was involved in head-on motor vehicle accident at high speed. He was initially evaluated at the pre-hospital setting and was reported to be hemodynamically stable. On arrival, his score on the Glasgow Coma Scale was 15, blood pressure 110/75 mm Hg, pulse rate 100/min, and respiratory rate 17/min. The patent had a deep scalp laceration, signs of recent nasal bleeding and facial bruising suggestive of a high-energy head injury while he was also complaining of a mild mid-epigastrium pain.
DR after blunt abdominal injury is a rare trauma condition. Correct diagnosis is often difficult and is usually established late raising significantly the associated mortality and morbidity. Single or serial plain chest radiographs with a high index of suspicion are diagnostic in many cases of DR [1, 4, 5]. However, missed cases result in herniation of the abdominal organs into the chest which finally enlarges the diaphragm defect. Chronic intermittent abdominal or chest pain, constipation, strangulation and perforation of the involved abdominal viscera are symptoms and consequences associated with the progressive herniation of the abdominal organs into the chest. As lung on the affected side is compressed, shortness of breath, dyspnea, and respiratory infections appear .
Tears of the diaphragm usually originate at the musculotendinous junction, mostly in the posterolateral aspect of the hemidiaphragms. The majority of these tears are on the left side. Either the relative weakness of the left hemidiaphragm or the protective effect of the liver on the right side represents possible explanations. Irrespective of the cause, right-sided rupture is associated with increased severity of injury and, therefore, increased mortality and morbidity rates . Approximately 80-90% of diaphragm injuries are related to automobile accidents. Falls or crush injuries to the diaphragm are rarer injury mechanisms. Lateral-impact automobile accident is three times more likely to cause a DR than any other impact type [7, 8].
Representative case series with combined diaphragmatic rupture (DR) and head injury
As soon as the diagnosis of a DR is established a surgical repair is warrant to prevent possible complications. A midline laparotomy is the advocated approach for repair of acute diaphragmatic trauma as it offers the possibility of diagnosing and repairing other associated intra-abdominal injuries. However thoracoscopy or laparoscopy in hemodynamically stable patients represents valid alternatives for the diagnosis and repair of a missed diaphragmatic injury especially in cases of penetrating left thoraco-abdominal trauma. Generally, repair with non-absorbable simple sutures is adequate in most cases . The use of mesh should be reserved for chronic and large defects [16, 17].
In our case, the combined abdominal and head injury confused the diagnostic field. Concomitant maxillofacial injuries as well as the deep scalp laceration in a patient with repeated episodes of vomiting rendered traumatic brain injury as the most likely diagnosis. However, the imaging investigation ruled out a central nervous system lesion as the cause of the patient’s symptoms i.e. vomiting. The consistency of symptoms as well as the alterations of pain characteristics during the initial phase of patient’s observation was the main arguments for the additional imaging workup . The pathognomonic sign in the chest x-ray with the stomach or the nasogastric tube in the hemithorax was not present in the chest radiography conducted at the trauma resuscitation unit. However, a nasogastric tube placement was contraindicated in our patient due to maxillofacial injuries and additionally a high quality chest x-ray could not be obtained until a work-up that could reliably rule out a cervical spine injury conducted.
Within the framework of a more meticulous investigation in order to delineate occult pathology to justify the clinical symptoms, a second chest x-ray under more appropriate conditions at the radiology department was obtained. The presence of the stomach within the left hemithorax was observed. Abdominal CT scan confirmed the herniation of the stomach into the chest and additionally ruled out any associated intraabdominal injuries. An urgent laparotomy at the base of DR was conducted. Regarding the repair technique we used intermittent non absorbable suture material in order to approximate the edges of the diaphragmatic defect. We assumed that the use of a prosthetic mesh in the given case with the relatively small diaphragmatic defect would increase the risk of infection and the procedure cost without corresponding benefits in the long term.
Increased level of suspicion is essential in order to diagnose timely blunt DR in multiple trauma patients. Early diagnosis can lead to the proper surgical management and reduce the incidence of hernia related complications.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Matsevych OY: Blunt diaphragmatic rupture: four years’ experience. Hernia. 2008, 12 (1): 73-78. 10.1007/s10029-007-0283-7.View ArticlePubMedGoogle Scholar
- Shah R, Sabanathan S, Mearns AJ, Choudhury AK: Traumatic rupture of diaphragm. Ann Thorac Surg. 1995, 60 (5): 1444-1449. 10.1016/0003-4975(95)00629-Y.View ArticlePubMedGoogle Scholar
- Turhan K, Makay O, Cakan A, Samancilar O, Firat O, Icoz G: Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac Surg. 2008, 33: 1082-1085. 10.1016/j.ejcts.2008.01.029.View ArticlePubMedGoogle Scholar
- Nau T, Seitz H, Mousavi M, Vecsei V: The diagnostic dilemma of traumatic rupture of the diaphragm. Surg Endosc. 2001, 15 (9): 992-996. 10.1007/s004640090096.View ArticlePubMedGoogle Scholar
- Guth AA, Pachter HL, Kim U: Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg. 1995, 170 (1): 5-9. 10.1016/S0002-9610(99)80242-6.View ArticlePubMedGoogle Scholar
- Boulanger BR, Milzman DP, Rosati C, Rodriguez A: A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma. 1993, 35 (2): 255-260. 10.1097/00005373-199308000-00014.View ArticlePubMedGoogle Scholar
- Lee WC, Chen RJ, Fang JF, Wang CC, Chen HY, Chen SC,et al: Rupture of the diaphragm after blunt trauma. Eur J Surg. 1994, 160 (9): 479-483.PubMedGoogle Scholar
- Sharma OP: Traumatic diaphragmatic rupture: not an uncommon entity–personal experience with collective review of the 1980's. J Trauma. 1989, 29 (5): 678-682. 10.1097/00005373-198905000-00024.View ArticlePubMedGoogle Scholar
- Reiff DA, McGwin G, Metzger J, Windham ST, Doss M, Rue LW: Identifying injuries and motor vehicle collision characteristics that together are suggestive ofdiaphragmatic rupture. J Trauma. 2002, 53 (6): 1139-1145. 10.1097/00005373-200212000-00018.View ArticlePubMedGoogle Scholar
- Chughtai T, Ali S, Sharkey P, Lins M, Rizoli S: Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases. Can J Surg. 2009, 52 (3): 177-181.PubMed CentralPubMedGoogle Scholar
- Simpson J, Lobo DN, Shah AB, Rowlands BJ: Traumatic diaphragmatic rupture: associated injuries and outcome. Ann R Coll Surg Engl. 2000, 82 (2): 97-100.PubMed CentralPubMedGoogle Scholar
- Chen JC, Wilson SE: Diaphragmatic injuries: recognition and management in sixty-two patients. Am Surg. 1991, 57 (12): 810-815.PubMedGoogle Scholar
- Pfannschmidt J, Seiler H, Böttcher H, Karadiakos N, Heisterkamp B: Diaphragmatic ruptures: diagnosis–therapy–results, experiences with 64 patients. Aktuelle Traumatol. 1994, 24 (2): 48-51.PubMedGoogle Scholar
- Balci AE, Kazez A, Eren S, Ayan E, Ozalp K, Eren MN: Blunt thoracic trauma in children: review of 137 cases. Eur J Cardiothorac Surg. 2004, 26 (2): 387-392. 10.1016/j.ejcts.2004.04.024.View ArticlePubMedGoogle Scholar
- Ilgenfritz FM, Stewart DE: Blunt trauma of the diaphragm: a 15-county, private hospital experience. Am Surg. 1992, 58 (6): 334-338.PubMedGoogle Scholar
- Hanna WC, Ferri LE: Acute traumatic diaphragmatic injury. Thorac Surg Clin. 2009, 19 (4): 485-489. 10.1016/j.thorsurg.2009.07.008.View ArticlePubMedGoogle Scholar
- Kuhn R, Schubert D, Wolff S, Marusch F, Lippert H, Pross M: Repair of diaphragmatic rupture by laparoscopic implantation of a polytetrafluoroethylene patch. Surg Endosc. 2002, 16 (10): 1495-10.1007/s00464-002-4503-z.View ArticlePubMedGoogle Scholar
- Patselas TN, Gallagher EG: The diagnostic dilemma of diaphragm injury. Am Surg. 2002, 68 (7): 633-639.PubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.