Left strangulated diaphragmatic hernia 3 years following a penetrating chest injury. A rare case report

Abstract

Introduction

Diaphragmatic hernias, particularly those resulting from trauma, present significant surgical challenges. Delayed presentations are common, as symptoms may emerge years after the initial injury due to progressive herniation driven by negative intrathoracic pressure.

Case presentation

We report a case of a 64-year-old male who presented with acute symptoms suggestive of a strangulating left-sided diaphragmatic hernia, three years post-penetrating chest trauma from a knife injury. Imaging studies, including X-rays and CT scans, confirmed the diagnosis by revealing bowel loops within the thoracic cavity and associated pleural effusions.

Discussion

Emergency laparotomy revealed necrotic bowel in the pleural space and a diaphragmatic defect. Surgical management involved resection of the necrotic bowel and repair of the diaphragmatic defect. This case illustrates the potential for delayed but life-threatening complications following chest trauma and underscores the importance of considering diaphragmatic hernia in differential diagnoses.

Conclusion

Clinical vigilance is crucial in patients with a history of thoracic trauma presenting with gastrointestinal symptoms. Early imaging and prompt surgical intervention are essential to reduce the risk of severe morbidity and mortality associated with delayed diaphragmatic hernia presentations.

Highlights

• •Rare case of left strangulated diaphragmatic hernia in an adult, occurring 3 years after chest trauma.
• •Delayed presentation shows silent progression of Diaphragmatic hernias, stressing long-term vigilance
• •Imaging was key for diagnosis and guided urgent surgery revealing necrotic bowel and diaphragmatic defect
• •Early recognition and prompt surgery are vital to prevent fatal complications after thoracic trauma.

1. Introduction

Diaphragmatic hernias are a significant surgical concern, particularly when they develop following trauma. They can be classified as congenital or acquired, with the latter often resulting from penetrating or blunt injuries to the thoracoabdominal region. Among these, left-sided diaphragmatic hernias are more prevalent due to the anatomical protection offered by the liver on the right side, making the left diaphragm more susceptible to injury and subsequent herniation [1,2]. This case report discusses a 64-year-old male who presented with acute symptoms of a strangulating left-sided diaphragmatic hernia, three years post a penetrating knife injury to the chest.

The delayed presentation of diaphragmatic hernias is not uncommon, as symptoms may take years to manifest following an initial traumatic event. This phenomenon is attributed to gradual herniation of abdominal contents into the thoracic cavity, often exacerbated by negative intrathoracic pressure [3,4]. In this case, the patient's history of chest trauma and subsequent gastrointestinal complaints underscore the need for heightened clinical awareness and diagnostic vigilance in similar cases.

Imaging studies such as X-rays and CT scans play a crucial role in diagnosing diaphragmatic hernias. They can reveal characteristic findings such as bowel loops in the thoracic cavity and pleural effusions that may complicate the clinical picture. The management of these hernias typically involves surgical intervention, which is critical in cases where strangulation occurs, as prompt treatment can significantly reduce morbidity and mortality [5,6]. This report aims to highlight the complexities surrounding delayed presentations of diaphragmatic hernias and the importance of timely surgical intervention. This work has been reported in line with the SCARE criteria [7].

1.1. Case presentation

A 64-year-old male presented with a one-day history of sudden-onset left abdominal pain. The pain was sharp in nature, persistent throughout the time, and radiated to the right side of the abdomen and the back. The pain progressively worsened but was temporarily relieved following administration of intravenous analgesia. The patient reported a loss of appetite, generalized body weakness, and six episodes of projectile vomiting of recently eaten food, with each episode measuring approximately 50mls. He also reported an inability to pass stool for three days prior to admission but was able to pass flatus and there was no history of abdominal distension, dysuria or polyuria. Additionally, he reported intermittent fevers but denied any respiratory or cardiovascular symptoms, including cough, chest pain, fatigue, breathlessness, or chest tightness.

The patient had a history of trauma where by three years prior to this admission, he sustained a penetrating knife injury to the left side of the chest during a fight. At that time, an abdominal X-ray was performed, revealing no evidence of an abdominal defect, and the wound was sutured. The patient was discharged with oral medications. Two years later, he began experiencing fluid leakage from the injury site, prompting another hospital admission. Approximately 2 l of serosanguinous fluid were drained, and the patient was treated before being discharged home.

One year following the fluid leakage incident, the patient presented with the current symptoms of abdominal pain and associated gastrointestinal complaints.

The patient is a known hypertensive on regular medications, including Amlodipine 10 mg once daily and Telmisartan H (one tablet daily).

On general examination, the patient was conscious, not pale, jaundiced, or cyanosed, and there was no lower limb edema. His blood pressure was 147/91 mmHg, pulse rate 50 bpm, temperature 36.7, and oxygen saturation 95 % on room air.

The abdomen had normal contours, moved with respiration, and showed an inverted umbilicus with no visible scars or masses. Tenderness was noted in the left upper quadrant, but there was no palpable organomegaly. Percussion was tympanic, and three bowel sounds were present.

Respiratory system examination revealed reduced chest expansion on the left side and a centrally positioned trachea. The left lower lung field was dull on examination, with decreased breath sounds noted in the same region. No crepitations or wheezes were detected.

The provisional diagnosis was small bowel obstruction with differentials of peptic ulcer disease and urinary tract infection. Laboratory results showed normal leukocyte count (WBC 8.30 × 10⁹/l), Hb of 14 g/dl, and platelet count of 270 × 10⁹/l. Random blood sugar was 5.2 mmol/l, H. pylori test was negative and Urinalysis showed no feature of urinary tract infection.

An ultrasound revealed fluid collection in the left costophrenic recess, suggestive of left pleural effusion. Chest X-ray (Fig. 1) confirmed a left pleural effusion involving approximately 30 % of the left hemithorax with consolidation where Abdominal X ray (Fig. 2) revealed dilated bowel loops. A CT scan (Fig. 3, Fig. 4, Fig. 5) conducted the following day demonstrated a 2 cm defect in the left diaphragm with protrusion of small bowel loops into the left hemithorax, consistent with a left diaphragmatic hernia. It also revealed a 100 % left pleural effusion causing complete atelectasis of the left lung with mediastinal shift towards the right. CT of the abdomen and pelvis showed dilated small bowel loops with multiple air-fluid levels and a transition point at the diaphragmatic hernia site. Twisting of herniated small bowel loops in the left hemithorax indicated complete small bowel obstruction secondary to incarcerated and strangulated left diaphragmatic hernia.

Fig. 1.

Chest X-ray confirmed a left pleural effusion involving approximately 30 % of the left hemi thorax with consolidation.

Fig. 2.

Abdominal X-ray showing dilated bowel loops.

Fig. 3.

CT scan showing a 2 cm defect in the left diaphragm with protrusion of small bowel loops into the left hemi thorax and dilated bowels.

Fig. 4.

CT scan showing atelectasis of the left lung.

Fig. 5.

Axial CT scan showing Diaphragmatic defect and atelectasis of the left lung.

Emergency laparotomy revealed necrotic herniated small bowel (jejunum) and omentum (Fig. 6, Fig. 7, Fig. 8) within the left pleural cavity with a hernia defect in the left diaphragm (Fig. 9). The necrotic segments were mobilized and resected, with an end-to-end anastomosis performed between the jejunum and ileum. Approximately 250 cm of jejunum was resected. The pleural cavity was irrigated with 4 l of normal saline, a chest tube was placed, and the diaphragmatic defect was repaired using nylon sutures. The abdominal cavity was irrigated with 6 l of normal saline, and a drain was inserted before the abdomen was closed in layers.

Fig. 6.

An image illustrating part of necrotic small bowel.

Fig. 7.

An image illustrating part of necrotic omentum.

Fig. 8.

An image illustrating dissected part of necrotic small bowel and omentum.

Fig. 9.

An image showing diaphragmatic defect/ hernia.

The patient was admitted to the High Dependency Unit (HDU) for three days and started on Meropenem 1 g TDS and Metronidazole 500 mg. This was followed by Gentamicin and Flucloxacillin. The patient recovered well and was discharged after 14 days. He was then scheduled for weekly follow up visits at surgical clinic where he made a total of 4 visits and during the last visit the patient was well with no complication.

2. Discussion

The case of this 64-year-old male illustrates several key aspects of managing left-sided strangulating diaphragmatic hernia post-trauma. Initially, his presentation with acute abdominal pain, vomiting, and signs of bowel obstruction prompted further investigation. The history of penetrating chest injury three years prior was pivotal in diagnosing his current condition. Such delayed presentations can often lead to misdiagnosis or underestimation of severity if not properly investigated [8,9].

Imaging findings were critical in establishing the diagnosis. The CT scan revealed a defect in the diaphragm with herniated bowel loops, confirming a strangulated hernia. This aligns with literature indicating that CT imaging is the gold standard for identifying diaphragmatic defects and assessing associated complications such as pleural effusion and lung atelectasis [10]. In this case, the presence of necrotic bowel necessitated urgent surgical intervention, emphasizing the critical role of early diagnosis in preventing irreversible ischemic bowel injury.

The surgical approach involved laparotomy, which allowed for direct visualization and management of the hernia contents. Although laparoscopic surgery is a recognized alternative for hernia repair due to its minimally invasive nature and faster recovery time, it was not feasible in this case. In our setting, laparoscopic procedures are not covered by the national insurance scheme, and the patient lacked private insurance coverage, making the option financially inaccessible. Moreover, we do not have sufficient expertise or instrumentation to perform advanced laparoscopic surgeries—only basic laparoscopic procedures are done, and most operations are still performed via the open method. Additionally, the presence of suspected bowel necrosis necessitated an approach that would allow thorough inspection and resection, further justifying the choice of open surgery. The resection of necrotic bowel segments and repair of the diaphragmatic defect are consistent with established protocols for treating strangulated hernias [11]. Postoperative care included antibiotic therapy and monitoring for complications, which is crucial given the high risk associated with such procedures.

3. Conclusion

This case emphasizes the importance of considering past trauma in patients presenting with acute abdominal symptoms. The potential for chronic complications following an initial injury necessitates thorough follow-up and evaluation when symptoms arise. Moreover, it serves as a reminder that even seemingly resolved traumatic injuries can have long-term consequences that require careful management. Therefore, routine clinical follow-up should be encouraged for patients with a history of chest or abdominal trauma, and a low threshold for imaging is advisable when new or unexplained symptoms develop, to aid in early detection of delayed complications.

Abbreviations

CT Scan

Computed Tomography scan

WBC

White Blood Cells

Hb

Hemoglobin

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request”.

Ethics approval

Ethical approval was not applicable.

Funding

Not applicable.

Authors' contributions

AAK and AK did Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing and all authors validated the study and approved the final version of the manuscript.

Guarantor

AAK and AK are the guarantors of the study.

Declaration of competing interest

The authors declare that they have no conflict of Interests.

Data availability

Not applicable.