Delayed diagnosis of blunt traumatic diaphragmatic hernia

Abstract

A 52-year-old man presented with a 3-day history of left shoulder-tip pain and shortness of breath, in the background of abdominal pain for 3 weeks. The patient had been admitted 4 months previously following a fall onto his left posterior chest wall, when he sustained a left-sided pneumothorax and fractures of the left 6th, 7th and 8th ribs posteriorly. At that time a computed tomography scan showed a left-sided pneumothorax with associated basal atelectasis and consolidation. On this, the second admission, initial observations were stable, apart from a mild tachypnoea. Abdominal examination was normal, but respiratory auscultation revealed bowel sounds in the left hemithorax. The chest radiograph showed a new left-sided pneumothorax and large bowel in the left chest (Figure 1). Abdominal radiography confirmed this, with some mildly dilated loops of bowel. A computed tomography scan demonstrated a left diaphragmatic rupture with associated intra-thoracic incarcerated large bowel, a left hydropneumothorax and mediastinal shift to the right (Figures 2 and 3). Subsequently, the patient underwent a transverse colectomy with colostomy formation, along with diaphragmatic repair through a left thoraco-abdominal approach. Gastrointestinal continuity was later restored electively. </jats:p