Delayed presentation of traumatic diaphragmatic rupture with tension colothorax and strangulation of the transverse colon

Abstract

A 26-year-old man presented to emergency department with respiratory distress. The initial diagnosis after chest X-ray was massive haemothorax, after insertion of a chest drain and further investigations, it turned up to be a rare case of a delay presentation of traumatic diaphragmatic rupture (DR) (after 1 year of the initial trauma). After excessive resuscitation of the patient in the emergency department, the patient underwent an emergency laparotomy which revealed ischaemic transverse colon herniated into the chest through a 7 cm diaphragmatic defect. Resection of the ischaemic bowel had been done, and the patient admitted to Intensive Therapy Unit (ITU) postoperatively. The patient had an uneventful recovery and discharged home on postoperative day 9. As DR after thoracoabdominal trauma is a rare condition that can be missed at initial presentation, we would like to highlight the main challenges in diagnosing and managing similar cases after reviewing related cases in the literature.

Background

Diaphragmatic rupture (DR) after thoracoabdominal trauma is a relatively uncommon condition that can be missed at the initial presentation. DR may also occur several months after the initial trauma. Dyspnoea and severe respiratory distress are the most common presenting symptoms; however, other non-specific obstructive symptoms such as nausea, vomiting and constipation may be presented if there is involvement of the small or large bowel or herniation of abdominal viscera into the chest. We did a literature review of the relevant articles using PubMed and Google Scholar search engines using the keywords (Traumatic diaphragmatic rupture/hernia, Tension Colothorax and delay presentation), and most of the case reports or the case series that we found have reported initial misdiagnosis with respiratory problems, with many patients undergoing related urgent procedures. In a recent case series that reported a single institution’s experience of DR, 6 out of 14 cases reported were diagnosed intraoperatively¹ DR remains a significant diagnostic challenge, and we would like to present a case report of a delayed and unusual presentation of traumatic DR after missed potential opportunities for diagnosis.

Case presentation

A 26-year-old male patient presented to our emergency department (ED) reporting symptoms of progressively worsening shortness of breath and chest pain as well as nausea, vomiting and constipation over the preceding 5 days. He had a history of penetrating thoracic trauma at the left costal margin 16 months ago, also two superficial stab wounds to the upper abdomen. CT scan was performed at the time of the initial penetrating trauma, was reported as ‘a small area of low attenuation with mild fat stranding at the lower aspect of the left anterior chest wall, which may represent an entry wound site, however no peritoneal breach’. The patient has self-discharged from the ED after having his wounds sutured. He subsequently represented on two different occasions to the ED (at 9 and 14 months later) with nausea, vomiting and abdominal discomfort, particularly after eating large meals. On the first occasion, blood tests were done in the ED, showing no abnormality. On the second occasion, chest X-ray (CXR) was undertaken, which was also reported as normal (figure 1). His abdominal examination was unremarkable on both occasions, and his symptoms were treated as gastritis.

Figure 1.

Chest X-ray 14 months after the initial trauma.

During this acute presentation, the patient was brought in urgently by an ambulance with significant respiratory distress. He reported that he was feeling unwell for 3–4 days with shortness of breath and difficulty in breathing, associated with reduced appetite, nausea and vomiting. He also had a single fainting episode and dizziness on standing. He had neither opened his bowels nor passed flatus in 5 days. On arrival to ED, he was hypoxic with 87% oxygen saturation despite high-flow oxygen, and his respiratory rate was 29 breaths/min. He was clammy, pale and tachycardic with a heart rate of 122 beats/min (bpm) and with a blood pressure of 101/87 mm Hg. He was apyrexial and fully alert. Physical examination revealed reduced breath sounds in the left hemithorax. He has been investigated with portable CXR which revealed complete opacification of the left lung, with an elevated left hemidiaphragm (figure 2).

Figure 2.

Chest X-ray (16 months after the initial trauma): complete opacification presents in the left lung, with an elevation of left hemidiaphragm and deviation of the trachea to the opposite side (to the right).

He clinically deteriorated in resuscitation bay and developed cerebral hypoperfusion with poor responsiveness, a heart rate of 130 bpm and systolic blood pressure of 45 mm Hg. An intercostal chest drain was inserted immediately for suspected tension haemothorax, which drained 1800mls of serosanguineous fluid. His vital parameters and cerebral perfusion were improved. The drain was clamped, and he has transfused three units of packed red cells and two units of fresh frozen plasma. Laboratory blood tests revealed an elevated white cell count of 30.56×10⁹/L, elevated C-reactive protein of 643 mg/L and elevated lactate of 3.2 mmol/L. Pretransfusion haemoglobin was 151 g/L. Sodium was 126 mmol/L, potassium 5.5 mmol/L, urea 18.1 mmol/L and creatinine 117 µmol/L. Cardiothoracic surgeons have reviewed the patient and noted that the blood in the drain was not clotted. Therefore, a repeat chest X-ray was performed, which showed improved lung markings and confirmed correct drain placement.

Investigations

The chest drain was unclamped and CT of the chest was performed with contrast to evaluate for any intrathoracic bleeding. There was no active bleeding in the chest; however, the radiologist has reported the presence of dilated fluid-filled bowel loops above the left diaphragm. A nasogastric tube was inserted, and a repeated CT of the abdomen was performed, which showed a posterior diaphragmatic defect on the left side, with herniation of the transverse colon through the defect. There was a reduced enhancement of the bowel wall despite contrast administration, dilated colonic and small bowel loops proximal to this was noticed, and a collapsed descending colon distal to the herniated segment was also noticed (figure 3), which has confirmed the diagnosis of delayed presentation of traumatic DR with tension colothorax and strangulation of the transverse colon.

Figure 3.

CT chest and abdomen: diaphragmatic rupture on the left whereby the transverse colon has herniated through the small diaphragmatic defect and its integrity looks compromised with hypoenhancement of the bowel wall. Proximal to this, the colon is dilated, as are the small bowel loops. The distal descending colon is collapsed. Normal appearances of the solid or pelvic viscera.

Treatment

The patient underwent an emergency laparotomy, which revealed a 7 cm diaphragmatic defect at the centre of the left side of the diaphragm. There was herniation of a 25 cm-long loop of the distal transverse colon into the left thoracic cavity with proximal dilatation of large and small bowel loops, and a collapsed left colon distally, with normal calibre. The incarcerated bowel loops were completely non-viable with an offensive odour. However, it was not perforated, and there was no faecal contamination or pneumoperitoneum. Resection of the ischaemic bowel segment was performed (25 cm) with the formation of end colostomy on the right side. The middle colic artery was preserved. The staple line of the left colon was oversewn. The abdominal and thoracic cavities were thoroughly washed out, and a drain was placed in the pelvis. The lung was not expanding after reducing the intestines back into the abdomen; therefore, another chest drain was inserted into the lower left hemithorax. The diaphragmatic defect was successfully repaired with a double layer of non-absorbable sutures.

Outcome and follow-up

The patient was nursed in intensive care for 3 days postoperatively, with a nasogastric tube on free drainage and administration of intravenous antibiotics. On day 4, the thoracic and abdominal drains were removed. The patient was discharged on the ninth day postoperatively with oral antibiotics. The patient declined chest drain for presumed empyema before his hospital discharge.

Discussion

Background and history

• DR after thoracoabdominal trauma is a rare condition, accounts for about 0.8%–5% of reported injuries.² It is often missed in 7%–66% of the cases.³ Late diagnosis is usually associated with herniation of abdominal contents into the thorax. Delayed presentation of diaphragmatic hernia (DH) accounts for about 30% of DR cases.⁴ DH occurs in about 1%–7% of the patients with DR caused by blunt trauma and 10%–15% of patients who had a history of penetrating trauma.⁵

• DR was first described during autopsy by Sennertus in 1541 and was first diagnosed in live patient by Bowditch in 1853 but the first case reported to be diagnosed and treated by Walker was in 1900.⁶

• The mechanism of delayed presentation of DR after thoracoabdominal trauma is not yet clear; however, there are various hypotheses, one of them is the frequency of the delayed diagnosis or detection of the silent DR as it is only manifested when herniation occurs.⁶ Various phases of DR were reported in 1974.⁷ Initially, there is an acute phase at the time of injury, followed by a delayed phase with herniation of the abdominal contents into the chest and finally obstruction phase with complications, which is what happened in our case.

Issues highlighted with diagnosis and management

In this case report, we wanted to highlight the main issues that we experienced in managing a case of a delay presentation of DH, and to address the most common problems that have been approached in similar cases or case reports, which we can summarise in the following points:

• First, delay in diagnosis and management of the patients causes an increase in the severity of the complications that the patients present with.

• Second, the management pitfalls of DH, which can be managed as tension pneumothorax or haemothorax (as what happened in this case), which can cause further harm to the patient rather than treating his condition.

Delayed presentation widely ranging between 24 hours⁸ and about 50 years,⁹ which is mostly on left side of the diaphragm.¹ Most of the cases were missed on the initial assessment and were discharged and represented with more severe complications. In one of the studies included 45 patients who presented with traumatic DH, 16/45 had a delayed presentation with an increase in mortality rate to 25% compared with 3% when diagnosed in the acute presentation.¹⁰ Our patient had strangulated colon involved in the hernia, which needed to be resected with stoma formation, and the patient stayed in the ITU for 3 days postoperatively.

Patients with DH could present with a wide range of non-specific symptoms such as breathing-related symptoms, pain (chest or abdominal) or even asymptomatic presentation,¹¹ which can cause confusion during the differential diagnosis and cause mismanagement with unnecessary procedures that can cause harm more than benefit to the patient.

Management

Our patient had emergency laparotomy, which revealed a 7 cm diaphragmatic defect through which the transverse colon was herniated through into the chest. The patient had a bowel resection and stoma formation, and he recovered very well postoperatively.

Other options of the repair reported in the literature are through laparoscopy or through thoracoscopy, which is more technically challenging and had similar outcomes when compared with laparotomy regarding morbidity or mortality or length of stay table 1).¹²

Table 1.

Reported similar cases in the last 40 years

First author	Year	Cases (n)	Age	Gender	Site of the hernia	Diagnosis	Content of the sac	Delayed presentation	Management	Defect size	Repair type	Mechanism of trauma	Reference
Hegarty et al	1978	25	Male 34.2 Female 24.4	M 18 F 7	Left 24 Right 1	Chest X-ray 15 barium study 10 intraoperative 1 postmortem 2	Colon 18 Stomach 10 Small bowel 4 Spleen 2	5 months–8 years	Laparotomy 13 Thoracotomy 7 Thoracoabdominal 2 Refused/died 3	Not mentioned	Not mentioned	Penetrating 22 Blunt 3	13
Price et al	1983	1	41	M	Left	Chest X-ray	Colon	2 months	Left thoracotomy	4 cm	Interrupted 3/0 silk	Penetrating (stab)	14
Radin et al	1985	1	38	M	Left	Chest X-ray	Transverse colon (perforated)	5 years	Laparotomy	7 cm	Not mentioned	Penetrating (stab)	15
Henzler et al	1988	1	25	F	Left	Chest X-ray	Gastrointestinal	5 months	Left thoracotomy	Not mentioned	Not mentioned	Blunt (RTA)	16
Phipps et al	1988	1	45	M	Left	Chest X-ray/gastrografin	Splenic flexure (perforated)	18 months	Laparotomy	5 cm	Not mentioned	Penetrating (stab)	17
Slim et al	1998	1	54	M	Left	Chest X-ray/barium study/CT	Stomach, splenic flexure, omentum, spleen	13 months	Laparoscopy	12 cm	Mesh polypropylene	Blunt	18
Faul et al	1998	1	59	M	Left	Chest X-ray	Transverse colon	40 years	Laparotomy	Not mentioned	Not mentioned	Blunt (RTA)	19
Singh et al	2000	1	53	M	Right	CT	Liver, gall bladder, stomach, colon	50 years	Thoracoabdominal	Not mentioned	Mesh	Blunt	9
Vermillion et al	2001	1	25	M	Left	Gastrografin/CT	Transverse colon (perforated)	6 years	Laparotomy	5 cm	Interrupted non-absorbable	Penetrating (stab)	20
Pojarliev et al	2003	1	23	M	Left	Contrast study	Stomach, small bowel, large bowel	6 months	Laparoscopic	Not mentioned	Polypropylene mesh	Blunt (RTA)	21
Petrakis et al	2003	1	26	M	Right	Chest X-ray/CT	Liver, gall bladder, small bowel	4 years	Laparotomy	Not mentioned	Two layers non-absorbable mattress sutures	Blunt (RTA)	22
Sirbu et al	2004	1	67	M	Bilateral	CT	Left: stomach, splenic flexure, spleen Right: liver	Left: 24 hours Right :10 days	Left: laparotomy Right: right thoracotomy	15 cm left	Left: interrupted non-absorbable Right: Gore-tex patch	Blunt (RTA)	8
Goh et al	2004	1	35	F	Left	CT	Stomach, splenic flexure, omentum	11 Days	Laparotomy	10 cm	Not mentioned	Blunt	23
Rossetti et al	2005	1	28	M	Right	CT	Not mentioned	18 months	Laparoscopy	Not mentioned	Non-absorbable interrupted stitches	Blunt	2
Ramdass et al	2006	1	20	M	Left	CT	Transverse colon (perforated)	5 years	Thoracoabdominal	Not mentioned	Not mentioned	Penetrating (stab)	24
Hariharan et al	2006	1	64	M	Left	CT	Spleen (portal hypertension)	28 years	Declined surgery	N/A	N/A	Penetrating (stab)	25
Christie et al	2007	1	48	F	Right	CT	Right kidney, right ureter, transverse colon, liver, gallbladder	10 years	Declined surgery	Not mentioned	N/A	Blunt (RTA)	26
Launey et al	2007	1	48	F	Right	Sonography/CT	Liver	10 days	Thoracoscopically	Not mentioned	Not mentioned	Blunt (RTA)	27
Thorac et al	2007	1	48	M	Right	CT	Liver	10 days	Posterolateral thoracotomy/right subcostal laparotomy	12 cm	Gor-tex patch	Blunt (RTA)	28
Rafi et al	2008	1	36	M	Left	N/A	Gastric volvulus						29
Kelly et al	2008	1	22	M	Left	Chest X-ray/CT	Transverse colon (perforated)	6 months	Thoracoabdominal (anterior, left side)	Not mentioned	Primary sutured 1/0 vicryl	Penetrating (stab)	30
Ruiz-Tovar et al	2008	23 (16 delayed)	N/A	M 17 F 6	Right 6 Left 16 Bilateral 1	N/A	N/A	N/A	Laparotomy	Not mentioned	Primary closure 14 Mesh 2	Blunt 21 Penetrating 2	11
Mizobuchi et al	2009	1	60	M	left	Chest X-ray/CT	Small bowel	10 months	Video-assisted thoracoscopy	Not mentioned	Primarily closure, non-absorbable	Blunt	31
Kafih et al	2009	1	68	M	Left	Chest X-ray	Transverse colon (perforated)	8 years	Thoracoabdominal	Not mentioned	Not mentioned	Blunt (RTA)	32
Walchalk et al	2010	1	57	F	Right	CT	Stomach	1 year	Laparotomy	Not mentioned	Not mentioned	Blunt (RTA)	33
Wani et al	2010	1	18	M	Left	OGD	Strangulated stomach	5 years	Laparotomy (started laparoscopy)	Not mentioned	Not mentioned	Blunt (RTA)	34
Lal et al	2011	1	32	M	left	Barium study	Stomach, spleen	4 years	Laparotomy (left subcostal)	10 cm	Mattress sutures, non-absorbable	Blunt	35
Çipe et al	2011	1	44	M	Intrapericardial	CT	Stomach, transverse colon and omentum	6 years	Laparotomy	Not mentioned	Mesh (dual mesh)	Blunt (RTA)	36
Khan et al	2011	1	32	M	Left	CT	Transverse colon (perforated)	5 years	Laparotomy	7 cm	Not mentioned	Penetrating (stab)	37
Guner et al	2011	8	29–76	M 5 F 3	Right	CT 8 contrast study 1	Small bowel 8 liver, colon 7	5–22 years	Right anterolateral thoracotomy 8 with subsequent laparotomy 2	Not mentioned	Dual mesh 7 polypropylene mesh 1	Blunt (RTA) 8	38
Kuppusamy et al	2012	1	28	M	Right	Chest X-ray/CT	Liver	3 days	Thoracotomy	Not mentioned	Not mentioned	Blunt (RTA)	39
Houston et al	2012	1	55	M	left	CT	Stomach	8 months	Laparoscopy	10 cm	Primary sutured	Blunt	40
Hajong et al	2012	1	30	M	Left	CT	Stomach	3 years	Laparotomy	Not mentioned	Non-absorbable suture	Penetrating (stab)	41
Dwari et al	2013	1	44	M	Left	Barium study/CT	Bowel loops, left kidney	15 days	Thoracoabdominal	Not mentioned	Single-layer non-absorbable suture	Blunt	42
Ganie et al	2013	11	N/A	M 11	Left 9 Right 2	CT 11	Isolated stomach 2 Stomach and large bowel 3 Isolated large bowel 2 Stomach spleen 2 Liver 2	9–12 months	Thoracotomy+laparotomy 9 Thoracotomy 2	Not mentioned	Interrupted mattress non-absorbable	Not mentioned	43
Kastanakis et al	2013	1	67	M	Right	CT	Liver	5 days	Thoracoabdominal	Not mentioned	Primarily closure	Blunt	44
Chatzoulis et al	2013	1	43	M	Left	Chest X-ray	Transverse colon (perforated)	15 years	Left thoracotomy+laparotomy	6 cm	Two layers: first: non-absorbable interrupted second: continues absorbable	Penetrating (gunshot)	45
Al Skaini et al	2013	1	30	M	Left	Chest X-ray/CT	Stomach, small bowel	2 years	Left anterolateral thoracotomy	Not mentioned	Primary sutured, non-absorbable	Blunt (RTA)	46
Williamson et al	2014	1	82	M	Left	CT	Gastric volvulus, large bowel, small bowel, pancreas	60 years	Non-operative (patient died)	N/A	N/A	Blunt (RTA)	47
Ampatzidou et al	2015	1	35	F	Left	Chest X-ray/CT	Stomach	1 year	Left posterolateral thoracotomy	Not mentioned	Interrupted non-absorbable sutures	Blunt (RTA)	48
Dinc et al	2015	2	33 42	M 2	Left 1 Right 1	CT	Small and large bowel ascending colon, caecum, pancreas, duodenum	3 years 28 years	Laparotomy delayed laparotomy	6 cm 15 cm	Primary suture, non-absorbable	Penetrating Blunt	49
Pakula et al	2015	1	37	M	Left	CT	Stomach, pancreas, omentum, colon, small bowel	25 years	Laparotomy	10 cm	Mesh (biological)	Blunt (RTA)	50
Falidas et al	2015	1	28	M	Left	Chest X-ray/barium study/CT	Stomach	4 months	Laparotomy	6 cm	Two layers non-absorbable	Blunt (RTA)	51
Ain Atif et al	2016	1	56	F	Right	CT	Bowel loops	8 years	Laparotomy (delayed)	3 cm	Mattress sutures, non-absorbable	Blunt (RTA)	52
Wakai et al	2017	1	57	M	Left	CT	Perforated stomach, spleen, tail of the pancreas	3 months	Laparotomy	10 cm	Primary suture	Blunt (RTA)	53
Corbellini et al	2017	14 (3 delayed)	31 33 28	M	Left	CT	N/A	11 months 46 months 96 months	N/A	N/A	N/A	N/A	1
Chern et al	2018	1	22	M	Left	CT	Splenic flexure of the colon (perforated)	2 years	Laparotomy	7–10 cm	Biosynthetic mesh	Penetrating (stab)	54
Tavakoli et al	2019	1	65	M	Right	Abdominal X-ray/CT	Small bowel	2 months	Laparotomy	4 cm	Primary suture non-absorbable	Blunt	55
Topal et al	2019	1	25	M	Left	CT	Omentum, splenic flexure	1 year	Laparotomy	3 cm	Two layer silk	Penetrating	56
Zhao et al	2019	40	15–65	M 24 F 16	Left 32 Right 8	X-ray 30 CT 40	N/A	4 months–21 years	Thoracotomy 38 with subsequent laparotomy 4 thoracoabdominal incision 2 (5.0)	3–17 cm	Primarily in 36 polypropylene mesh 4	Blunt 21 (traffic accident 12 others 9) Penetrating 15	57

OGD, oesophago-gastro-duodenoscopy; RTA, Road-Traffic-Accident.

Learning points.

• Diaphragmatic rupture (DR), especially without diaphragmatic hernia, can be easily missed during the initial assessment. DR should be in the differential diagnosis of any patient who presents with dyspepsia or shortness of breath, especially those with the previous history of thoracoabdominal trauma to avoid iatrogenic complications from unnecessary procedures.

• Low threshold of suspicion, particularly in penetrating trauma and increased awareness that many cases will not be visible on chest X-ray.

• On the other hand, follow-up CT for the patients who got involved in thoracoabdominal trauma could recognise undetected DR and prevent consequent complications.