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Delayed infarction of the stomach following diaphragmatic injury
Injury Vol. 28, No. 9-10, pp. 690-692, 1997 © 1997 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020-1383/97 $17.00+ 0.00
ELSEVIER
PII: S0020-1383(97)00143-5
Delayed infarction of the stomach following diaphragmatic injury J. R. P. Gibbons and J. McGuigan T h e R o y a l Victoria H o s p i t a l , Belfast, N o r t h e r n I r e l a n d , U K
Injury, Vol. 28, No. 9-10, 690-692, 1997
Introduction T h e i n c i d e n c e of a r u p t u r e d d i a p h r a g m is i n c r e a s i n g in o u r society, m a i n l y as a r e s u l t of r o a d traffic a c c i d e n t s . Early d i a g n o s i s is u s u a l l y possible, b u t r e q u i r e s a h i g h i n d e x of s u s p i c i o n . S t r a n g u l a t i o n in diaphragmatic rupture is o f t e n o v e r l o o k e d o r improperly treated and the mortality rate remains high. A case of visceral i n f a r c t i o n 5 m o n t h s f o l l o w i n g i n j u r y is r e p o r t e d . T h e p a t i e n t r e m a i n s fit a n d well, t e n y e a r s after o p e r a t i o n .
Case report A 20-year-old university student was admitted to hospital in September 1984, following a road traffic accident in which he was a front seat passenger wearing a seat belt. On admission he was found to be semiconscious and radiological examination of the chest and skull were entirely normal. The patient recovered consciousness and was well enough to be discharged the next day. He was admitted as an emergency in January 1985, complaining of severe left-sided hypochondrial pain for 24 h. This was also associated with colicky abdominal pain and total dysphagia. He had felt 'something tearing inside him' immediately before the pain started. On physical examination he was found to be in a shocked state with obvious respiratory distress. Examination of the thorax showed a tracheal shift to the right with absent breath sounds on the left side. The apex beat could not be palpated. A chest X-ray confirmed gross mediastinal shift to the right side, with decreased lung markings and a fluid level on the left side. It was felt that the patient had a tension pneumothorax and a chest drain was inserted anteriorly in th left second intercostal space. No air escaped and the fluid in the drainage tube did not rise and fall with respiration. A second chest X-ray showed the drain above an apparent air-filled viscus. The patient's condition deteriorated rapidly and his systolic blood pressure fell to 80 mmHg, with a pulse rate
of 140, and he became semiconscious. At this stage it was felt that he had a delayed rupture of the diaphragm with a herniated viscus. An attempt was made to pass a nasogastric tube but it could not be advanced further than the distal oesophagus. With further evidence of his deteriorating condition a large needle was passed into the left hemithorax anteriorly. This produced an efflux of foul gas and faeculant fluid. After the removal of two litres of fluid, the nasogastric tube could be advanced and the needle was removed. The patient regained consciousness and his condition became stable. General anaesthesia was induced and a double-lumen endotracheal tube was subsequently passed. With the patient in the left lateral position an incision was made through the eighth intercostal space and extended anteriorly to give access to the peritoneal cavity. The stomach, spleen and transverse colon had passed through a small peripheral diaphragmatic tear and occupied the left pleural cavity. The stomach had undergone a volvulus and most of the body was infarcted. The colon and spleen appeared congested but healthy. The tear in the diaphragm was carefully enlarged under direct vision above and below the defect. When all the abdominal organs had been returned to the peritoneal cavity, the body of the stomach was resected and the antrum anastomosed with the proximal gastric remnant using continuous Vicryl (R) in two layers. The diaphragm was repaired with linen sutures. The patient had a stormy convalescence with basal collapse of the left lung and a persistent effusion which continued to drain for 10 days. A contrast study showed an intact stomach with normal mucosa and adequate gastric emptying. He was discharged, and when reviewed 10 years following his surgery, was 5 kg below his ideal weight but otherwise well, and is now practising as a lawyer.
Discussion I s o l a t e d r u p t u r e of t h e d i a p h r a g m d u e to b l u n t t r a u m a is u n c o m m o n a n d o n l y a f e w cases a r e r e p o r t e d of s u b s e q u e n t visceral s t r a n g u l a t i o n 1. B r e a r l e y a n d T u b b s 2 r e p o r t e d in 1981 a series of 894 cases a d m i t t e d to t h e B i r m i n g h a m A c c i d e n t
Case reports
Hospital with blunt injuries to the trunk. Of this number, 18 suffered from a ruptured diaphragm but no case of visceral strangulation was seen. In all cases of blunt abdominal and chest trauma, the possibility of a ruptured diaphragm should be kept in mind. Physical findings are frequently atypical but a careful history, especially in the delayed case, may indicate a rupture. In many cases, multiple system injury is a feature and fractured ribs, fractures of the pelvis, splenic injury and fractures of the long bones are often associated with diaphragmatic injury. Chest pain is a common feature and may be referred to the shoulder. Dysphagic symptoms and regurgitation may be associated with obstruction at the cardiooesophageal junction and colicky pain occurs with gastrointestinal obstruction. With the development of pleural exudate and compression atelectasis of the lung, the patient complains of increasing breathlessness. In 1853, Bowditch ~ described the signs in a leftsided diaphragmatic defect. These included prominence and immobility of the left hemithorax, displacement of cardiac dullness to the right, absent breath sounds in the left hemithorax and bowel sounds audible in the chest. These signs are valid for delayed herniation as well as for acute rupture and early herniation. Where rupture is not diagnosed early and the patient progresses to obstruction, the mortality rate is higher in those patients presenting with infarction of a viscus'. It has been estimated that 85 per cent of cases of strangulation occur within 3 years of associated trauma and that trauma may account for up to 90 per cent of strangulated diaphragmatic hernias 4. Radiological examination may show a hydropneumothorax and often the presence of air will be noted within an abdominal organ in the chest cavity. Introduction of a nasogastric tube into the stomach and subsequent X-ray study will confirm an intrathoracic stomach and also aid in decompressing the organ. When abdominal organs have passed through a small diaphragmatic rupture, passage of a nasograstric tube may prove impossible. In such circumstances, when time permits, the diagnosis may be confirmed by computerized tomography or MRI. Some investigators have introduced an artificial pneumothorax to demonstrate an intrathoracic herniation but false negative results and complications have occurred 5. In the case reported, the patient went through the three phases described by Grimest Initially he had an acute phase with loss of consciousness and subsequent recovery. During the second or latent phase it is classical for viscera to herniate into the thorax following periods of maximal respiratory effort. Finally, with herniation of the stomach through a small defect, obstruction and infarction can occur. The patient presented with severe respiratory distress and became hypotensive. A misdiagnosis of tension pneumothorax was made and an attempt to release this was undertaken by inserting a chest drain. The stomach was tough enough to deflect the
691
chest drain and high pressure remained within the stomach, which continued to compress the lung and displace the mediastinum. Shock occurs because of heart displacement and interference with venous return to the heart. In this type of emergency the use of a trocar when a tube cannot be passed to deflate the stomach prevents rupture of that organ with all its subsequent infective problems. As a result of trocar introduction, the patient became stable and a nasogastric tube could then be passed. Once the patient has been resuscitated, surgical exploration must be undertaken immediately and the infarcted organ excised, as in the case described. Shah 7 describes, in a review of 980 patients, that in 14.6 per cent the diagnosis was delayed. In this series, the mortality was 17 per cent in those patients in whom an acute diagnosis was made, and the morbidity was mainly due to pulmonary complications. Although in acute cases of diaphragmatic rupture, especially with possible abdomen injury, the authors would approach repair via an abdominal route, they do stress that in delayed rupture, because of the adhesions between abdominal and thoracic organs, the approach should be through a thoracotomy. In any case, the thoracotomy incision can easily be converted into a thoraco-abdominal operation if the situation found warrants further exploration. With an abdominal approach and injury to organs such as the spleen, a rupture of the diaphragm can be missed, with subsequent migration of abdominal organs, and another emergency situation will result. Brooks~ in his series of 42 cases of ruptured diaphragm, operated on 41 patients through a thoracotomy, and in every case the abdominal contents were easily returned and the diaphragm repaired from above. In the delayed case, as distinct from acute rupture of the diaphragm, a thoracotomy is the best approach to both left and right diaphragmatic injuries. It is a wise precaution to advise those patients who have been at risk of a diaphragmatic injury following an accident, to mention this fact to their doctor if they develop abdominal or chest symptoms at a later date. Delayed rupture of the diaphragm is too frequently missed and all should be aware of its significance.
References 1 Christiansen L. A., Blichert-ToftJ. and gertelsen S. Strangulated diaphragmatic hernia. A clinical study. Am ] Surg 1974; 128: 175. 2 Brearley S. and Tubbs N. Rupture of the diaphragm in blunt injuries of the trunk. Injury 1981; 12: 480. 3 Bowditch L. Diaphragmatic hernia. Buffalo Med ] 1853; 9: 65. 4 Carter B. N., Guiseffi J. and Felson B. Traumatic diaphragmatic hernia. Am ] Roentgenal 1951; 65: 56. 5 Morley J. E. Traumatic diaphragmatic rupture. G African Med ] 1974; 48" 325.
692
Injury: International Journal of the Care of the Injured Vol. 28, No. 9-10, 1997
6 Grimes O. F. Traumatic injuries of the diaphragm: Diaphragmatic hernia. Am J Surg 1974; 128: 175. 7 Shah R., Sabanathan S., Mearns A. J. and Choudhury A. K. Traumatic rupture of diaphragm. Ann Thorac Surg 1995; 60: 1444. 8 Brooks J. W. Blunt traumatic rupture of the diaphragm. Ann Thorac Surg 1978; 26" 199.
P a p e r accepted 18 August 1997.
Requests for reprints should be addressed to: Mr J. R. P. Gibbons MBE,FRCS,Jenkins Barn, Horsham Road, Cranleigh, Surrey GU6 8DU, UK.
ELSEVIER
PII: S0020-1383(97)00143-5
Delayed infarction of the stomach following diaphragmatic injury J. R. P. Gibbons and J. McGuigan T h e R o y a l Victoria H o s p i t a l , Belfast, N o r t h e r n I r e l a n d , U K
Injury, Vol. 28, No. 9-10, 690-692, 1997
Introduction T h e i n c i d e n c e of a r u p t u r e d d i a p h r a g m is i n c r e a s i n g in o u r society, m a i n l y as a r e s u l t of r o a d traffic a c c i d e n t s . Early d i a g n o s i s is u s u a l l y possible, b u t r e q u i r e s a h i g h i n d e x of s u s p i c i o n . S t r a n g u l a t i o n in diaphragmatic rupture is o f t e n o v e r l o o k e d o r improperly treated and the mortality rate remains high. A case of visceral i n f a r c t i o n 5 m o n t h s f o l l o w i n g i n j u r y is r e p o r t e d . T h e p a t i e n t r e m a i n s fit a n d well, t e n y e a r s after o p e r a t i o n .
Case report A 20-year-old university student was admitted to hospital in September 1984, following a road traffic accident in which he was a front seat passenger wearing a seat belt. On admission he was found to be semiconscious and radiological examination of the chest and skull were entirely normal. The patient recovered consciousness and was well enough to be discharged the next day. He was admitted as an emergency in January 1985, complaining of severe left-sided hypochondrial pain for 24 h. This was also associated with colicky abdominal pain and total dysphagia. He had felt 'something tearing inside him' immediately before the pain started. On physical examination he was found to be in a shocked state with obvious respiratory distress. Examination of the thorax showed a tracheal shift to the right with absent breath sounds on the left side. The apex beat could not be palpated. A chest X-ray confirmed gross mediastinal shift to the right side, with decreased lung markings and a fluid level on the left side. It was felt that the patient had a tension pneumothorax and a chest drain was inserted anteriorly in th left second intercostal space. No air escaped and the fluid in the drainage tube did not rise and fall with respiration. A second chest X-ray showed the drain above an apparent air-filled viscus. The patient's condition deteriorated rapidly and his systolic blood pressure fell to 80 mmHg, with a pulse rate
of 140, and he became semiconscious. At this stage it was felt that he had a delayed rupture of the diaphragm with a herniated viscus. An attempt was made to pass a nasogastric tube but it could not be advanced further than the distal oesophagus. With further evidence of his deteriorating condition a large needle was passed into the left hemithorax anteriorly. This produced an efflux of foul gas and faeculant fluid. After the removal of two litres of fluid, the nasogastric tube could be advanced and the needle was removed. The patient regained consciousness and his condition became stable. General anaesthesia was induced and a double-lumen endotracheal tube was subsequently passed. With the patient in the left lateral position an incision was made through the eighth intercostal space and extended anteriorly to give access to the peritoneal cavity. The stomach, spleen and transverse colon had passed through a small peripheral diaphragmatic tear and occupied the left pleural cavity. The stomach had undergone a volvulus and most of the body was infarcted. The colon and spleen appeared congested but healthy. The tear in the diaphragm was carefully enlarged under direct vision above and below the defect. When all the abdominal organs had been returned to the peritoneal cavity, the body of the stomach was resected and the antrum anastomosed with the proximal gastric remnant using continuous Vicryl (R) in two layers. The diaphragm was repaired with linen sutures. The patient had a stormy convalescence with basal collapse of the left lung and a persistent effusion which continued to drain for 10 days. A contrast study showed an intact stomach with normal mucosa and adequate gastric emptying. He was discharged, and when reviewed 10 years following his surgery, was 5 kg below his ideal weight but otherwise well, and is now practising as a lawyer.
Discussion I s o l a t e d r u p t u r e of t h e d i a p h r a g m d u e to b l u n t t r a u m a is u n c o m m o n a n d o n l y a f e w cases a r e r e p o r t e d of s u b s e q u e n t visceral s t r a n g u l a t i o n 1. B r e a r l e y a n d T u b b s 2 r e p o r t e d in 1981 a series of 894 cases a d m i t t e d to t h e B i r m i n g h a m A c c i d e n t
Case reports
Hospital with blunt injuries to the trunk. Of this number, 18 suffered from a ruptured diaphragm but no case of visceral strangulation was seen. In all cases of blunt abdominal and chest trauma, the possibility of a ruptured diaphragm should be kept in mind. Physical findings are frequently atypical but a careful history, especially in the delayed case, may indicate a rupture. In many cases, multiple system injury is a feature and fractured ribs, fractures of the pelvis, splenic injury and fractures of the long bones are often associated with diaphragmatic injury. Chest pain is a common feature and may be referred to the shoulder. Dysphagic symptoms and regurgitation may be associated with obstruction at the cardiooesophageal junction and colicky pain occurs with gastrointestinal obstruction. With the development of pleural exudate and compression atelectasis of the lung, the patient complains of increasing breathlessness. In 1853, Bowditch ~ described the signs in a leftsided diaphragmatic defect. These included prominence and immobility of the left hemithorax, displacement of cardiac dullness to the right, absent breath sounds in the left hemithorax and bowel sounds audible in the chest. These signs are valid for delayed herniation as well as for acute rupture and early herniation. Where rupture is not diagnosed early and the patient progresses to obstruction, the mortality rate is higher in those patients presenting with infarction of a viscus'. It has been estimated that 85 per cent of cases of strangulation occur within 3 years of associated trauma and that trauma may account for up to 90 per cent of strangulated diaphragmatic hernias 4. Radiological examination may show a hydropneumothorax and often the presence of air will be noted within an abdominal organ in the chest cavity. Introduction of a nasogastric tube into the stomach and subsequent X-ray study will confirm an intrathoracic stomach and also aid in decompressing the organ. When abdominal organs have passed through a small diaphragmatic rupture, passage of a nasograstric tube may prove impossible. In such circumstances, when time permits, the diagnosis may be confirmed by computerized tomography or MRI. Some investigators have introduced an artificial pneumothorax to demonstrate an intrathoracic herniation but false negative results and complications have occurred 5. In the case reported, the patient went through the three phases described by Grimest Initially he had an acute phase with loss of consciousness and subsequent recovery. During the second or latent phase it is classical for viscera to herniate into the thorax following periods of maximal respiratory effort. Finally, with herniation of the stomach through a small defect, obstruction and infarction can occur. The patient presented with severe respiratory distress and became hypotensive. A misdiagnosis of tension pneumothorax was made and an attempt to release this was undertaken by inserting a chest drain. The stomach was tough enough to deflect the
691
chest drain and high pressure remained within the stomach, which continued to compress the lung and displace the mediastinum. Shock occurs because of heart displacement and interference with venous return to the heart. In this type of emergency the use of a trocar when a tube cannot be passed to deflate the stomach prevents rupture of that organ with all its subsequent infective problems. As a result of trocar introduction, the patient became stable and a nasogastric tube could then be passed. Once the patient has been resuscitated, surgical exploration must be undertaken immediately and the infarcted organ excised, as in the case described. Shah 7 describes, in a review of 980 patients, that in 14.6 per cent the diagnosis was delayed. In this series, the mortality was 17 per cent in those patients in whom an acute diagnosis was made, and the morbidity was mainly due to pulmonary complications. Although in acute cases of diaphragmatic rupture, especially with possible abdomen injury, the authors would approach repair via an abdominal route, they do stress that in delayed rupture, because of the adhesions between abdominal and thoracic organs, the approach should be through a thoracotomy. In any case, the thoracotomy incision can easily be converted into a thoraco-abdominal operation if the situation found warrants further exploration. With an abdominal approach and injury to organs such as the spleen, a rupture of the diaphragm can be missed, with subsequent migration of abdominal organs, and another emergency situation will result. Brooks~ in his series of 42 cases of ruptured diaphragm, operated on 41 patients through a thoracotomy, and in every case the abdominal contents were easily returned and the diaphragm repaired from above. In the delayed case, as distinct from acute rupture of the diaphragm, a thoracotomy is the best approach to both left and right diaphragmatic injuries. It is a wise precaution to advise those patients who have been at risk of a diaphragmatic injury following an accident, to mention this fact to their doctor if they develop abdominal or chest symptoms at a later date. Delayed rupture of the diaphragm is too frequently missed and all should be aware of its significance.
References 1 Christiansen L. A., Blichert-ToftJ. and gertelsen S. Strangulated diaphragmatic hernia. A clinical study. Am ] Surg 1974; 128: 175. 2 Brearley S. and Tubbs N. Rupture of the diaphragm in blunt injuries of the trunk. Injury 1981; 12: 480. 3 Bowditch L. Diaphragmatic hernia. Buffalo Med ] 1853; 9: 65. 4 Carter B. N., Guiseffi J. and Felson B. Traumatic diaphragmatic hernia. Am ] Roentgenal 1951; 65: 56. 5 Morley J. E. Traumatic diaphragmatic rupture. G African Med ] 1974; 48" 325.
692
Injury: International Journal of the Care of the Injured Vol. 28, No. 9-10, 1997
6 Grimes O. F. Traumatic injuries of the diaphragm: Diaphragmatic hernia. Am J Surg 1974; 128: 175. 7 Shah R., Sabanathan S., Mearns A. J. and Choudhury A. K. Traumatic rupture of diaphragm. Ann Thorac Surg 1995; 60: 1444. 8 Brooks J. W. Blunt traumatic rupture of the diaphragm. Ann Thorac Surg 1978; 26" 199.
P a p e r accepted 18 August 1997.
Requests for reprints should be addressed to: Mr J. R. P. Gibbons MBE,FRCS,Jenkins Barn, Horsham Road, Cranleigh, Surrey GU6 8DU, UK.