Traumatic Diaphragmatic Rupture – A Clinical Experience Over Two Decades

Introduction: Traumatic diaphragmatic rupture was onceonly reported in post mortem findings. But due to betteradvanced trauma and life support services and increasedsurvival of the trauma patients, these are now diagnosed withincreasing frequency. The purpose of this study was to presentour experience with its different mechanisms of ruptureand its management. The aim of this retrospective studywas to evaluate manifestations of effects of diaphragmaticrupture after thoraco-abdominal trauma, and to discusstheir epidemiology, diagnosis, nature and treatment with anaim to impart comprehensive timely management to reducemorbidity and mortality.Material and methods: It is the report of combined experienceof the authors on 18 patients with traumatic diaphragmaticrupture with (TDR) or without traumatic diaphragmatichernia (TDH) treated in two Medical College Hospitals inKolkata, from 1998 to 2019, and a retrospective analysis wasperformed. 9 patients who presented with severe injury withfeatures of internal injury were operated early and 9 with nonsevere injury were operated later.Results: Out of 18 patients, 14 had history of blunt traumaand 4 had history of penetrating trauma. 4 patients withpenetrating together with 5 with blunt injury were includedin the severe group and had undergone early surgery due tosuspected internal injuries. Out of these 9 patients, 5 patientshaving TDR and 1 having TDH died due hemorrhage and /or sepsis with a mortality of 33.33. TDH was diagnosed byimaging studies in 9 patients in non severe group while 1 wasdiagnosed intra operatively in the severe group.Conclusions: Though priority of a blunt or a penetratingtrauma patient involves resuscitation and early surgery whenindicated, careful understanding of mechanism of injury canguide the emergency surgeon to suspect and examine thediaphragm for any TDR to prevent further complication.In addition to X rays computer tomographic study whenavailable becomes helpful in preoperative planning of surgeryfor closure of TDR or TDH.

Sporadic Duodenal Gastrinoma causing Zollinger Ellison Syndrome – A Rare Case Report

Introduction: Gastrinoma is a rare gastrin secretingneuroendocrine tumor. Clinical manifestations are nonspecificgastrointestinal (GI) symptoms or as Zollinger EllisonSyndrome(ZES) which often delays the diagnosis in majorityof patients. Hence a high clinical index of suspicion iswarranted in patients who present with nonspecific GIsymptoms to rule out gastrinoma.Case report: We report a case of 55 year old female whopresented with long standing dyspepsia and chronic diarrhoeaand was diagnosed with Sporadic Duodenal Gastrinomaon detailed evaluation. She was treated with surgicalresection and pathologically diagnosed as well differentiatedneuroendocrine tumor, Gastrinoma – grade I after IHCanalysis. Patient was relieved of her symptoms and becameeugastrinemic after surgery.Conclusion: Any patient with refractory dyspepsia associatedwith long standing non specific abdominal symptoms shouldbe evaluated for Gastrinoma and treated accordingly to avoidmisdiagnosis and complications in the long run.

Delayed presentation of traumatic diaphragmatic rupture with complicated cholecystitis

The right-sided diaphragmatic rupture is often clinically occulted due to buffering effects of the liver and thus, erroneous diagnosis of such rupture may result in life-threatening conditions. A 44-year-old female who had a history of car accident in 2006 was admitted to our hospital for pleuritic pain. On the chest computed tomography, she was diagnosed with diaphragmatic rupture accompanied by herniation of hypertrophic left liver with complicated cholecystitis and we carried out cholecystectomy, reduction of the liver, pleural drainage, and primary closure of the diaphragm via thoracic approaches. Our case is presented in three unique aspects: herniation of left hemiliver, hypertrophic liver herniated up to the 4th rib level, and combination of complicated cholecystitis. Although the diagnosis of right-sided diaphragmatic rupture can be challenging for the surgeon, an early diagnosis can prevent further complications on the clinical presentation.

Ruptura diafragmática traumática: un diagnóstico que puede ser desapercibido / Traumatic diaphragmatic rupture: a diagnostic that could be unperceived

Paciente mujer de 17 años, procedente y residente de la provincia Ingavi, del Departamento de La Paz; ingresó al servicio de Emergencias del Instituto Nacional del Tórax (INT) con el antecedente de habersufrido tres semanas antes, una contusión accidental sobre el hemitórax derecho, durante un juego de fútbol, acompañada de pérdida de la conciencia y recuperación de la misma después de 30 minutos sin atención médica.

Traumatic Diaphragmatic Ruputure: 4-Year Clinical Experience

PURPOSE: A traumatic diaphragmatic rupture (TDR) is a diagnostic challenge and the associated injuries determine the outcome in those diagnosed early. A TDR has long been considered to be a marker of the severity of injury with an average reported Injury Severity Score (ISS) between 31 and 50. This report reviewed the TDR cases in order to emphasize the method and timing of the diagnosis, associated injuries and the outcome. METHODS: A retrospective analysis was performed on 30 patient treated for TDR between August 1998 and september 2002. RESULTS: The mean age of the patients was 33.4 years and the injury predomiantly affected males (male: female=2: 1). Blunt trauma by TA was the most common cause of the TDR (25 patients). The ruptured sites were on the left in 22 cases and on the right in 8 cases. The most common symptom was chest pain (23 cases) followed dyspnea (21 cases). Liver injuries and a pneumo-hemothorax were the most common associated injuries. The mean CRAMS scale was 6.47 and Injury Severity Score (ISS) was 18.93. Eighteen TDR cases were suspected based on the abnormal chest X-ray findings. Nineteen cases underwent surgery within 6 hours after the trauma (early diagnosis). Although many complications occurred in 11 cases, there were no lethal complications. The mean size of the diaphragmatic rupture was 9.77 cm and an intraabdominal organ herniation had not occurred in ruptures smaller than 6 cm. Surgical repair of the diaphragm was performed via a laparotomy in 20 cases and thoracotomy in 7 cases. A left side TDR was preferred to a laparotomy whereas a right sided TDR was preferred to a thoracotomy. Pulmonary complications (atelectasis, pneumonia, pleural effusion) occurred in 14 cases postoperatively. CONCLUSION: The patient's complaints and physical findings were not a reliable indicator of the diagnosis, but usually a manifestation of the associated injuries. A suspicion and routine chest X-ray was the most reliable diagnostic tool, even though the chest X-ray was normal in 12 cases. A high rate of early diagnosis can be achieved using an aggresive investigation protocol, suspicion and a combined radiologic evaluation in multiple trauma patients. Although pulmonary complications occurred in the early diagnosed cases, lethal complications and long term sequela were directly related to the time of diagnosis. The higher ISS had many complications (11 cases) but there were no lethal complications, long term sequela.

Hérnia diafragmática traumática / Traumatic diaphragmatic hernia

Traumatic diaphragmatic hernia is an uncommon but important problem in the patient with multiple injuries. Since diaphragmatic injuries are difficult to diagnose, those that are missed may present with latent symptoms of bowel obstruction and strangulation. The same may occur in the patients with stab wounds to the lower chest. Traumatic diaphragmatic hernia should be suspected on the basis of an abnormal chest radiograph in the trauma victim with multiple injuries. This article discuss about history, epidemiology, clinical signs and symptoms, diagnostic modalities, treatment and complications.