TRAUMATIC DIAPHRAGMATIC HERNIA WITH INTESTINAL OBSTRUCTION IN A CHILD: A CASE REPORT

Abstract

Diaphragmatic ruptures caused by blunt or penetrating trauma are relatively uncommon in children, however, they are the most commonly missed or delayed injuries in trauma patients because of its rarity and its coexistence with more obvious and serious injuries. We present a case of acute intestinal obstruction in a 6-year old boy with traumatic diaphragmatic hernia presented four years after trauma, underscoring the fact that clinical scenario in paediatric patients may not always correlate with the degree of severity of the injury and that some of the classical features of intestinal obstruction could be absent.

Introduction

Diaphragmatic ruptures caused by blunt or penetrating trauma are relatively uncommon in children, however, they are the most commonly missed or delayed injuries in trauma patients because of its rarity and the coexistence with more obvious and serious injuries^1-8. They occur in 3-7% of all thoracic and abdominal trauma¹. When diaphragmatic injuries are not diagnosed promptly, they present months or years after the initial trauma in about 9.5% to 61% of all cases¹. The late presentation could lead to pulmonary complications, chronic abdominal pain or acute bowel obstruction, which might result in morbidity and mortality^1,4.

There are three phases of diaphragmatic rupture as described by Grimes⁵. The first or acute phase is at the time of injury of the diaphragm, the second or delayed phase is because of transient herniation of the viscera, accounting for absence or intermittent non-specific symptoms. The third or obstruction phase results from complication of long standing herniation manifesting as obstruction and possible strangulation. Although it is uncommon , delayed diaphragmatic rupture is an important cause of bowel obstruction. Early recognition of these cases is important, so that operative intervention can be performed promptly to prevent tissue strangulation and necrosis that may result in high morbidity and mortality.

We present a case of acute intestinal obstruction in a 6-year old boy with traumatic diaphragmatic hernia who presented four years later in order to highlight the need for high index of suspicion.

Case Report

The patient is a 6-year old boy who presented with recurrent dry cough and difficulty in breathing which became worse after meals; there was no fever. The child had been hit by a reversing car at home four years earlier and sustained minor injuries that were managed in a primary health facility and discharged home. The parents however, noticed that the child subsequently started having recurrent episodes of non-productive cough and breathlessness which was worsened after meals; this was treated as asthma for four years at various health facilities. The patient was subsequently referred to Jos University Teaching Hospital, Jos, on account of a chest radiograph that showed homogenous opacity and an air-fluid level (Fig.1). On clinical and radiological/imaging examinations a diagnosis of left diaphragmatic rupture was made and the parents were counseled for surgery. The parents defaulted but two months later, the child was rushed to the emergency department on account of vomiting which was non-bilious with streaks of blood, constipation, fever, worsening breathlessness and cough, but there was no abdominal pain or distension. Examination revealed a child that was ill-looking, breathless and dehydrated with a temperature of 38.1⁰C, respiratory rate of 46/min, reduced chest movement, absent breath sounds and hyperactive bowel sounds on the left hemithorax. His oxygen saturation was however, 96% in room air and his heart rate was 124/min. The abdomen was flat with hyperactive bowel sounds. His complete blood count and electrolytes were normal. The patient was resuscitated and had left posterolateral thoracotomy that revealed a posterolateral diaphragmatic rupture with irregular edges, approximately 12 x 4 cm with herniation of loops of viable small bowel, transverse colon, stomach, greater omentum and left lobe of liver into the left thoracic cavity (Figs. 2&3). After sequential reduction of the abdominal viscera into the abdomen, the diaphragmatic defect (Fig. 4) was repaired primarily in two layers with prolene 1 suture without tension (Fig. 5). The left lung was noted to be collapsed but re-expanded gradually. A chest drain was placed and the chest was closed in layers. The post operative course was uneventful and the patient was discharged on the tenth post operative day. He has remained in good health with normal lung function after a follow-up period six months.

Fig. 1.

Chest X-ray showing air-fluid levels of bowel in the left chest

Fig.2.

Intra-operative findings showing small bowel in the chest

Fig.3.

This shows stomach in the chest

Fig. 4.

The diaphragmatic rupture

Fig.5.

Diaphragmatic repair

Discussion

Traumatic diaphragmatic hernia is uncommon in children and could occur after blunt or penetrating chest and/or abdominal trauma^2,3. The different mechanisms that result in diaphragmatic rupture after blunt trauma included avulsion of the attachments of the diaphragm or shearing of the stretched membrane after right or left lateral impact to the chest wall, rib fracture fragments directly penetrating the diaphragm, and a sudden increase in intra-abdominal pressure throughout the abdomen, with the relatively weak, unprotected diaphragmatic tear from the force⁵. Small diaphragmatic hernias might be realized months or even years later, when the patient became symptomatic^1,4 as was the case with the index patient. High index of suspicion for diaphragmatic hernia is required in patients with a previous history of chest and/or abdominal trauma presenting with atypical respiratory and abdominal symptoms in order to avoid delay and consequent morbidity and mortality. Some reports had shown that blunt trauma accounted for 68-75% while penetrating trauma was responsible for 25-32% of traumatic diaphragmatic injuries; road traffic crashes were the causes in 90% of cases^1,2.

The left hemi-diaphragm has been shown to be injured in 50 - 88% of patients who had blunt diaphragmatic rupture whereas right sided injuries were less frequent, occurring in 12 - 40% of cases^5,10. The right diaphragm appears to be protected from traumatic impact by the energy absorbing liver, thus accounting for the lower incidence of right sided ruptures ^5,6. The high frequency of left sided injuries has been attributed to an area of congenital posterolateral weakness ^5,7-10. Children however, show an approximately equal rate of left and right sided injuries which might be accounted by the increased mobility of the liver that gives less protection to the right hemidiaphragm than obtains in adults^3,5. Right sided diaphragmatic ruptures were often more difficult to diagnose in children which could result in diagnostic delay that constituted high morbidity and mortality^2,5. The index patient had a ruptured left posterolateral hemi-diaphragm with herniation of the left lobe of the liver and intestines.

It has been shown that 7% to 66% of diaphragmatic injuries in multitrauma patients remain undiagnosed^1,6. This diagnostic delay and failure to carry out appropriate intervention in the acute setting results in chronic diaphragmatic hernia with possibility of strangulation. This sequence was observed in the index patient.

The clinical signs of diaphragmatic hernia are usually non-specific, although respiratory distress is often prominent. Other symptoms may include cough, chest pain, shoulder pain and cyanosis^2,5. Symptoms were typically due to visceral herniation through the ruptured diaphragm. The diagnosis was usually made by radiological and imaging examinations because of the non-specific symptoms and should be performed early in suspected cases². The radiological features may include inability to see clearly the affected hemi-diaphragm, abnormal elevation of the hemi-diaphragm, air-fluid levels in the thorax, mediastinal shift and aberrant course of the nasogastric tube seen coiling back into the chest. These chest X-ray findings have a sensitivity of only 17% and many series in the literature have shown that 30 - 50% of initial chest radiographs were normal in patients with diaphragmatic rupture thus emphasizing the importance of repeated radiographs². The computed tomography scan and magnetic resonant imaging give clearer picture and also characterize the diaphragmatic defect; ultrasonography had been found useful, especially in unstable patients in the acute phase².

Operative intervention remains the main management for delayed traumatic diaphragmatic ruptures, most especially in the setting of an acute complication such as strangulation as in the index patient. Surgical repair is also required in all diaphragmatic rupture because there is no spontaneous healing of the diaphragm. The thoracic approach is usually recommended for chronic diaphragmatic hernias due to dense intrathoracic adhesions that could be encountered in such cases^1,6,7. This could be achieved either by Video assisted thorachoscopic surgery (VATS) or through a thoracotomy. Combined chest and abdominal approaches have been employed in some cases of strangulation^8,9. Laparoscopic surgery is another approach in the treatment of traumatic diaphragmatic ruptures in institutions where the facilities and expertise are available.

Conclusions

This case draws our attention to the fact that the diagnosis of traumatic diaphragmatic rupture could be missed at the initial trauma evaluation, most especially in children where other obvious injuries might be given high premium over diaphragmatic injuries that could present with atypical respiratory symptoms. A high index of suspicion is recommended in the initial assessment of patients with chest and/or abdominal blunt trauma; it is even more so when a patient presents with non-specific features sometime after chest and/or abdominal trauma.