Right side traumatic diaphragmatic hernia presented after 20 years with shortness of breath; a rare case presentation, and literature review

Abstract

Introduction

A right side diaphragmatic injury was linked to serious trauma to the abdomen, pelvis, and chest. The most significant type of injury was blunt abdominal trauma sustained in a car collision. The left side was more likely than the right to experience herniation. The stomach and colon were the most often herniated abdominal viscera. In the same location as the diaphragm rupture, there were rib fractures, hemothorax, and liver damage. Delayed diaphragmatic rupture with diaphragmatic hernia is rare and has a mysterious nature.

Case presentation

A 68 years old female patient who has repeated history of shortness of breath, for which she treated as lung infection presented with sudden exacerbation of shortness of breath, she witnessed history of blunt trauma 20 years back and up on investigation bowel herniation to the chest cavity diagnosed. Posteriolateral thoracotomy done, the herniated bowel reduced and the diaphragmatic defect repaired. The patient significantly improved and discharged from the hospital smoothly on 4th postoperative day.

Discussion

Careful recording of past history and physical examination are the best approaches in diagnosing delayed presentation of traumatic diaphragmatic rupture. CT scan with reconstruction of the diaphragm is helpful in both diagnosis and differential diagnosis. Surgical therapy after diagnosis is the best treatment.

Conclusion

Delayed right side diaphragmatic hernia is a rare entity resulting in grave consequences, In a patient with history of trauma there should be a high index of suspension and patients should undergo imaging and surgical management is the best treatment.

Highlights

• •Right side traumatic diaphragmatic hernia is a rare case presentation.
• •Delayed traumatic right side diaphragmatic hernia may present with shortness of breath even after 20 years of trauma.
• •Successful open surgical management in low and middle income country with has good outcome.

1. Introduction

Traumatic diaphragmatic injury (TDI) is an uncommon but potentially fatal post-traumatic problem. Diaphragmatic ruptures are occurs after thoraco-abdominal traumas (0.8–5 %). In 90 % of cases, they are left-sided. Because the liver often protects the diaphragm, right-sided TDI is particularly rarer. It might be challenging to diagnose and potential for delayed presentation. Although less frequent, right-sided diaphragm hernias can happen and are frequently misdiagnosed .Whatever the situation, TDI must be treated carefully as it might result in bowel strangulation and necessitate immediate surgery. Various methods have been reported for the definitive correction of diaphragmatic abnormalities. We report a traumatic right side diaphragmatic hernia 20 years after she sustained trauma which presented with shortness of breath and successfully managed surgically in low and middle income country and the work has been reported in line with SCARE criteria. [[1], [2], [3], [4]]

2. Case presentation

We present a 68 years old female patient who came from the rural part of the country presented with history of shortness of breath for long duration. For the above compliant she visits several health institutions including our hospital where she was informed that she has respiratory infection and medication was given for that. She was examined with chest X ray four times for same problem and she was told to have pneumonia and treated with antibiotics. The shortness of breath is exacerbated during activity and when she is at rest it usually improves. For this reason she restricted from most of her usual activity and only participated only in home based activity like cooking.

For the last two years the shortness of breath was exacerbated and even starts to limit waking for few distance and she visits private hospital where she again treated as pneumonia but had no improvement. Over the last 20 years except some intermittent discomfort over the abdomen she had no history of abdominal distension, no history of cramp abdominal pain that necessitates physician visit or no history of failure to pass feaces and flatus.

On her recent visit to our hospital the patient had shortness of breath even at rest with sudden exacerbation of one day duration; otherwise she had no chest tightness, no fever, no cough, no swelling over the extremity or other parts of the body and no history of known chronic medical illness. She has no known familial illness. On further history questioning she gave history of trauma and the mentioned problem came few years after she sustained trauma. She initially denied history of any trauma but later she remembered that she sustained trauma 20 years back where a wall of an old house collapse over right side of chest and abdomen where she visited this hospital and after chest X ray was taken, she sent home with anti-pain. She never taught that her problem is associated with the trauma she sustained while she visits several health facilities for the complaint of her illness. Because of incomplete medical history, lack of imaging modalities and skilled profession in interpreting the clinical condition and the available investigation our patient's problem was not identified on time.

On physical examination, she looks acutely sick looking in cardiorespiratory distress, Her blood pressure 110/70 mmHg; pulse rate 88/m; respiratory rate, 34; temperature,36.1 °C; oxygen saturation, 84 % with atmospheric air and 96 % with Face mask O₂. Other physical examination findings she have on chest was decreased air entry over the lower half of the right lung field and audible bowel sound over the right chest and there no pertinent finding on the other system. She was immediately put on face mask oxygen and laboratory examination and chest CT scan ordered.

Her laboratory results were as follows: WBC: 7.5 k/UL with neutrophil: 73.8 %, lymphocyte: 16.6 %, HCT: 38.4 %, PLT: 365 k/uL, Cr:0.7 mg/dl, ESR:5 mm/h. Chest shows bowel in right chest with defect in the diaphragm (Fig. 1, Fig. 2, Fig. 3).

Fig. 1.

Axial CT scan showing herniated bowel in the chest.

Fig. 2.

Coronal CT scan showing bowel herniated to the right chest cavity.

Fig. 3.

Sagittal CT scan image showing bowel in chest through diaphragmatic defect.

The patient was subsequently advised for surgical management after stabilized and further work up was done. After informed and written consent obtained from the patient she undergone right side posteriolateral thoracomy (since the minimal invasive surgery is not available in our set up) and the intraoperative finding was viable normal size transverse colon in the right which from adhesion with the lung and pericardium compressing the lung (Fig. 4) and there is 3 cm by 4 cm defect on the anteriolateral part of the diaphragm where the neck forms adhesion circumferentially to the herniated bowel. The liver is at its normal site and didn't herniate to the chest and with normal size and length of inferior vena cava which indicates the defect is acquired rather than congenital. There was no fluid or sign of intrapleural infection. The adhesion released gently and the bowel reduced to the abdomen after the neck was widened and the defect in the diaphragm was closed primarily without tension with silk no 2 stitch since the defect is small. Chest cavity closed after chest tube placed (Fig. 5). The post-operative course was smooth and the patients discharged from the hospital on 4th post-operative day with significant improvement and complete lung expansion. The patient is on regular follow up without any post-operative complication and the follow up chest x-ray shows fully expanded lung with on collection in the pleural cavity (Fig. 6).

Fig. 4.

Intraoperative imaging showing transverse colon in the right pleural cavity.

Fig. 5.

After the defect primarily repaired.

Fig. 6.

Follow-up X ray one month after the procedure.

3. Discussion

A right side diaphragmatic injury was linked to serious damage to the abdomen, pelvis, and chest. In the same location as the diaphragm rupture, there were rib fractures, hemothorax, and liver damage. Thus, it appeared that the force responsible for diaphragmatic rupture varied between left- and right-sided patients. The blunt blow to the right thoracic wall was the primary cause of the right-sided diaphragmatic rupture. The right lobe of the liver was the most often herniated organ in right-sided diaphragmatic hernias, and delayed presentation of the condition had a significant incidence of G-I tract herniation. The abdominal organ herniation appeared to change over time. Trauma to the thoracoabdominal region is blunt and accounts for 75 % of TDIs. Variable clinical presentations and a high frequency of accompanying life-threatening injuries in blunt TDIs may make it difficult to diagnose and treat the condition early, which might result in more difficult repairs. Diagnostic delays are more probable in cases of right-sided blunt TDIs because they are far less prevalent than left-sided ones, are more difficult to see on imaging examinations, are more commonly linked to other potentially fatal injuries, and tend to present more subtle. It might be particularly difficult to diagnose right-sided TDIs early on [5,6].

Due to the rarity of right side cases, the clinical appearance of a late-diagnosed diaphragmatic hernia necessitates distinct diagnostic and treatment strategies than those for acute diaphragmatic rupture. In patients with a history of trauma, it is important to keep this in mind while making a differential diagnosis. Without a strong index of suspicion and a variable time to diagnosis, traumatic diaphragmatic hernia remains a challenging diagnosis to make. The low frequencies of the illness and its vague clinical presentation have been linked to this. It has been recommended that a chest radiograph be used as the first imaging modality and that computed tomography be used as a reliable adjunct. [[7], [8], [9]]

The sensitivity and specificity of CT-scan for the diagnosis of blunt TDI are both good. When a diaphragmatic hernia is seen on a radiograph or helical CT scan, the diagnosis of blunt TDR can be made with ease. As a preliminary evaluation, “offside sign” is useful for penetrating TDR without hernia. Coronal/sagittal reconstruction on a CT scan is a reliable diagnostic method. [10,11]

Although they are not frequent, surgical repair is necessary for traumatized diaphragmatic injuries (TDIs) in order to treat or prevent herniation. While managing delayed diaphragmatic hernias can be difficult, it is possible to perform a repair that will lead to a satisfactory recovery and a low risk of recurrence with careful planning and an adaptable surgical strategy. An injury that is readily overlooked and can result in considerable morbidity and fatality [7,12].

A minimally invasive (VATS) or an open approach to patients with a delayed-presentation diaphragm hernia is safe and effective. The recommendation for surgical approach is based on patient characteristics, anatomic considerations, and surgeons' experience. Postoperative pulmonary complications including atelectasis are common following surgery for traumatic diaphragmatic hernia. Other complications include surgical infection, bleeding, respiratory failure, ileus, gastroesophageal reflux, chronic pain, hernia recurrence, and cardiac injury [13,14].

4. Conclusion

Post trauma delayed diaphragmatic hernia is rare. As a result, it is important to thoroughly look into the patient's history. Clinical symptoms together with physical findings should be taken into account while making the diagnosis. A reconstruction examination with CT scans of the chest and abdomen can greatly increase diagnostic accuracy. Surgical therapy should begin as soon as the diagnosis is established and before surgery, the surgical strategy and diaphragm repair techniques should be thoroughly assessed in order to have good outcome.

Consent

Written and Informed oral consent taken from the patient for publication and accompanying images and a copy of it can be presented upon request by editor in chief.

The patient is so much happy when we informed that we are going to publish, so that the other individual do not suffer for many years with similar illness.

Ethical approval

Ethical approval letter is obtained from our institution Ethical committee with a reference number of AHMC 20/12/23.

Funding

No source of funding.

Author contribution

Mekonnen Feyissa: main surgeon, reviewed the manuscript.

Dawi Girma: involved the perioperative patient care.

Admikew Bekele: reviewed the literature and prepared the manuscript.

Hiwot Tadesse: Involved in manuscript preparation and writing.

Guarantor

Mekonnen Feyissa.

Research registration number

Not applicable in our set up.

Conflict of interest statement

We declare that there is no conflict of interest.