Diaphragmatic hernia as a long-term complication of stab wounds of the chest

Presentation of diaphragmatic herniae during pregnancy and labour

We report two cases of pregnancy-related diaphragmatic hernia. Case one was a 36-year-old woman who presented in her ninth pregnancy, after eight vaginal deliveries. Eight months after a stab wound to the chest, she developed persistent vomiting. The diagnosis was made by chest X-ray after a contralateral central line had been inserted for parenteral nutrition. A 6 x 4 cm stab-induce defect in the diaphragm was repaired. Close by was a second healed diaphragmatic stab wound. Case two involved a 32-year-old woman with a history of repaired childhood diaphragmatic hernia. She developed atypical shoulder and precordial chest pain during labour. Delivery was achieved by the vaginal route, ventouse-assisted. Persistent pain and vomiting led to insertion of a nasogastric tube and the diagnosis was made on the subsequent chest X-ray. The omentum was very adherent to the lung and could only be mobilised via a thoracotomy, at which significant air leaks occurred but settled rapidly. The difficulties of diagnosis are discussed along with the embryology, mechanisms and management of this condition.

Delayed traumatic diaphragmatic hernia simulating acute tension pneumothorax

The diagnosis of acute diaphragmatic injury is difficult to establish in the immediate posttraumatic period. Patients with delayed diaphragmatic herniation frequently present months to years after the initial injury with manifestations of visceral incarceration, obstruction, ischemia from strangulation, or perforation. Patients with diaphragmatic herniation presenting with clinical tension pneumothorax are rare. We describe the case of a 23-year-old female who 16 weeks following a stab wound to the low chest presented with this clinical picture caused by herniation of abdominal viscera into the chest. A review of this entity and methods of discovery of delayed traumatic diaphragmatic herniation are described.

Delayed presentation of traumatic diaphragmatic hernia

More than 111 patients with traumatic diaphragmatic hernia (TDH) were treated in a 5 1/2-year period; eight (7.2%) were first recognized more than 30 days postinjury. All were men, and their average age was 33.4 years. Seven injuries were on the left side; one was on the right side. The mechanism of injury was equally divided between penetrating and blunt trauma. Chest roentgenographic abnormalities were seen in all patients. Visceral reduction and diaphragmatic repair, despite strangulation in four patients, was accomplished without mortality and with minimal morbidity. Delayed presentation of TDH is reviewed, emphasizing diagnostic features encountered in the emergency department (ED).

Abdominal injuries associated with penetrating trauma in the lower chest

A 5 year experience of 248 patients with isolated penetrating lower chest injury was reviewed. Twenty-two (15 percent) of the stab wounds and 46 (46 percent) of the gunshot wounds caused associated intraabdominal injury. Among those taken to the operating room for laparotomy, physical examination proved misleading in 40 percent of the patients with stab wounds and 30 percent of those with gunshot wounds. The diagnostic accuracy of peritoneal lavage, used selectively, was 93 per cent for the patients with stab wounds and 90 percent for those with gunshot wounds. The morbidity was high in patients with combined injuries, with major complications occurring in 27 percent of those with stab wounds and 43 percent of those with gunshot wounds. Two thirds or more of these complications were thoracic. There was one death (4 percent) among the patients with thoracoabdominal stab wounds and six (13 percent) among those with gunshot wounds.

Penetrating thoracoabdominal injuries

Twenty-three cases of penetrating thoracoabdominal injury are reviewed. Abdominal pain, tenderness and rigidity were found to be the most constant indicators of diaphragmatic penetration in these injuries (65 per cent). These features may occur as referred phenomena of purely thoracic injuries and persist as a result of the presence of an intercostal drainage tube used in the treatment of such injuries. There may be no abdominal signs in injuries of the diaphragm unaccompanied by any visceral damage or in injuries confined to the lesser sac. A high index of suspicion in the presence of a wound over the lower half of the chest is necessary to detect these lesions. Negative radiological findings do not exclude a diaphragmatic injury.

The thoracic component of a penetrating thoracoabdominal injury can usually be treated conservatively by aspiration or drainage of the pleural space, but laparotomy is advised for the repair of the abdominal viscera. The need for thoracotomy should be determined by the merits of the thoracic injury or the desirability of pleural toilet. The intra-abdominal injury may then be dealt with through the diaphragm. There is a greater tendency to pleural infection in thoracoabdominal injuries than in simple penetrating thoracic injuries, which is attributable to contamination by intestinal contents through the diaphragmatic tear. The mortality in this series was due to the abdominal injuries, the early recognition and treatment of which would have improved results.