Missed Diaphragmatic Rupture and Progressive ... - Springer Link

Case Study

European Journal of Trauma

Missed Diaphragmatic Rupture and Progressive Hepatothorax, 26 Years after Blunt Injury Tatijana Popovic1, Slobodan Nikolic2, Bojan Radovanovic1, Tomislav Jovanovic1

Abstract Background: Cases of blunt diaphragmatic rupture are not as common as other thoracoabdominal injuries and may pose a diagnostic challenge. Depending upon the size of the right hemidiaphragmatic rupture, herniation of liver may be partial, as progressive hepatothorax. The diagnosis of progressive hepatothorax coincides with the onset of the first symptoms of herniation. Case Study: In the patient presented here, the interval between the original injury and the onset of symptoms related to the herniation of the abdominal cavity organs in the thorax was 26 years. Herniation of abdominal organs into the thorax was apparently rather slow and asymptomatic. The first symptoms, 26 years after trauma, included epigastric pain, meteorism, nausea, and vomiting, and all of them were due to gastrothorax and elongated gaster. These symptoms were nonspecific and therefore interpreted as acute alcoholic gastritis. With deterioration of the patient’s condition, they were subsequently interpreted as subileus due to the strangulation of a portion of the elongated and dilated stomach. Conclusion: Laparoscopy proved to be the most reliable diagnostic method in this case. Key Words Blunt injury · Diaphragmatic rupture · Progressive hepatothorax Eur J Trauma 2004;30:43–6 DOI 10.1007/s00068-004-1327-7

Introduction Cases of blunt diaphragmatic rupture are not as common as other thoracoabdominal injuries and may pose a diagnostic challenge. Right-sided rupture is less frequent than left-sided rupture. However, depending upon the size of the right hemidiaphragmatic rupture, herniation of the liver may be complete, with acute symptoms, or it may be partial, as a progressive hepatothorax [1]. The diagnosis of progressive hepatothorax coincides with the onset of the first symptoms of herniation, i.e., symptoms by respiratory and/or circulatory systems. Herein, we describe a case of progressive hepatothorax with rupture of the right hemidiaphragm, diagnosed 26 years after the initial injury. Case Study A 52-year-old male, chronic alcoholic, sustained injuries in a car accident 26 years ago in which he was involved as the driver. Upon impact, he was thrown from his vehicle, lost consciousness and was subsequently taken to the regional medical center by ambulance. He was treated conservatively, but due to subjective respiratory problems and the suspicion of potentially serious thoracic injury, a chest X-ray was taken 6 days later (Figure 1). A series of right-sided rib fractures (V–VII) and hemothorax were diagnosed. Right-sided hemothorax was drained, and the second control radiography was taken 18 days after the injury. This showed a slight elevation of the right-sided dome of the diaphragm (Figure 2). Considered cured, he was discharged 20 days after sustaining the injury. 16 years later, the same patient was treated for acute bronchitis. A chest X-ray revealed ele-

General County Hospital of the City of Pozarevac, Serbia and Montenegro, 2 Institute of Forensic Medicine, School of Medicine, Belgrade, Serbia and Montenegro. 1

Received: April 14, 2003; revision accepted: July 24, 2003.

European Journal of Trauma 2004 · No. 1 © Urban & Vogel

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Popovic T, et al. Progressive Hepatothorax, 26 Years after Injury

Figure 1. Anteroposterior roentgenogram of the right hemithorax, 6 days after the injury. Note the level of hydrothorax (hemothorax).

Figure 2. Anteroposterior roentgenogram of the thorax, 18 days after the injury. Note the slight elevation of the right-sided dome of the diaphragm.

vation of the right hemidiaphragm, but it was considered to be unrelated to previous trauma. 26 years after sustaining the original injury, the patient complained about nonspecific abdominal problems: epigastric pains, meteorism, nausea, vomiting. Since the patient was not in a life-threatening situation, a less aggressive approach was taken at first. Ultrasonography was performed, which failed to reveal the exact cause of symptoms, but only showed the enlarged liver. Gastroscopy revealed the elongated gaster, which raised suspicions of hiatus hernia. As none of these methods were successful in revealing the correct cause of symptoms, contrast gastroduodenography was performed (Figure 3), followed by explorative laparoscopy. Progressive hepatothorax was diagnosed at the right hemidiaphragm. The right hemidiaphragm contained a circular defect of approximately 15 cm in width that had formed over time at the side of the rupture. The hepatothorax was accompanied by a gastric hernia into the thorax involving herniation of the antral part of elongated gaster into thoracic cavity. The gastrothorax was potentially life-threatening to the patient, although not at that time. The patient was operated on. The liver, with the largest part of its right lobe passing into the thoracic cavity through an opening in the diaphragm, was reached by classic laparotomy through the front abdominal wall. This part of the lobe was used to pull a part of the gaster and, thus, elongated it, which brought the

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pylorus into the right hemithorax. Adhesions between prolapsed abdominal and chest organs were relatively easily removed, and the organs returned to their original anatomic positions. The existing traumatic defect in the diaphragm was covered with mersilene mesh. Classic reconstruction of the front abdominal wall followed. 6 months later, radiography (Figure 4) and lung radioscopy were performed and showed pleural adhesions and signs of chronic pleurisy on the right side. Satisfactory motions or excursions of the right hemidiaphragm indicated proper functioning of diaphragm and phrenic nerve. Discussion The incidence of indirect diaphragmatic ruptures is small, only between 1% and 8% [2–5]. With severe blunt thoracoabdominal trauma, the incidence is slightly higher, up to 22% [1]. Ruptures are most common in road accidents. However, rupture of the left hemidiaphragm is much more common than rupture of the right hemidiaphragm [1, 3, 6–9]. This difference can be explained by the biodynamic effect of blunt trauma on the thoracoabdomen, as well as the anatomic relationship between organs in the abdominal cavity [1]. Therefore, proper diagnosis of right hemidiaphragmatic rupture can be very difficult and is deferred in almost half of all cases [1]. If the rupture of the diaphragm is large, acute herniation may develop, usually accompanied by signs of “acute abdomen”. If the rupture is small, it is followed by the chronic phase where a hernia is formed that grad-



Figure 3. Preoperative contrast gastroduodenography, 26 years after the injury, showing herniation of the antral part of the elongated gaster into the thoracic cavity.

Figure 4. Anteroposterior roentgenogram of the thorax, 6 months after the operation, showing pleural adhesions and signs of chronic pleurisy on the right side.

ually transforms into an opening. Therefore, parts of abdominal organs or entire abdominal organs occasionally prolapse through this opening. Since isolated or combined herniations of liver, stomach, and colon may develop through the rupture of the right hemidiaphragm, symptoms may vary. Their manifestation depends on the extent to which the organ is herniated, what kind of organic and functional changes it has suffered, and whether the organ is fixated or mobile. These symptoms are often accompanied by either permanent or temporary dyspnea that becomes more apparent upon muscular effort, sudden posture change, after a heavy meal, etc. These symptoms are usually prolonged, nonspecific, and not constant. Common symptoms and signs are shoulder pain, distension and/or immobility of the hemithorax, intestinal signs in the thorax, slight but recurrent effusions due to torsion of the inferior vena cava, congestion and edema of the liver, acute portal hypertension, sometimes BuddChiari syndrome, etc. [1]. The interval between injury and the diagnosis of a rupture of the diaphragm may vary from a few weeks to a few years [4–7, 9–11]. Besson & Saegesser [1] reported 44 years as the longest interval. In this case, the interval between the original injury and the onset of symptoms related to the herniation of the abdominal cavity organs in the thorax was 26 years. Radiography performed 16 years after the accident showed the elevation of the right diaphragm which could suggest the development of progressive hepatothorax, but due to lack of symptoms, at that time, the

doctors could neither connect the results of radiography with the previous injury nor make the diagnosis of progressive hepatothorax. The symptoms of progressive hepatothorax were obviously less severe than those diagnosed much later, which took 10 years to develop. The patient had no symptoms at all for 26 years: herniation of abdominal organs into the thorax was apparently slow and asymptomatic. The first symptoms, 26 years after the trauma, included epigastric pain, meteorism, nausea, and vomiting, and all of them were due to gastrothorax and the elongated gaster. These symptoms were nonspecific and therefore interpreted as acute alcoholic gastritis. With deterioration of the patient’s condition, they were subsequently interpreted as subileus due to the strangulation of a portion of the elongated and dilated stomach. The symptoms could also have been caused by a hiatus hernia, which was suspected after gastroscopy. Ultrasonographic enlargement of the liver in our patient, accompanied by fat metamorphosis, was accounted for by chronic alcoholism, and not by congestion of progressive hepatothorax. Failure to detect potential hepatothorax through the rupture of the diaphragm immediately after the initial injury may be explained by the development of hemothorax on the same side masquerading as prolapsed liver tissue. In general, there are difficulties with radiologic diagnosis of right hemidiaphragmatic injuries [9]. However, early diagnosis of blunt diaphragmatic rupture is directly related to the diagnoses of other injuries. More severe injuries (high Injury Severity


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Score) typically lead to numerous procedures, which, in turn, lead to greater chances for complete diagnosis, as diaphragmatic ruptures are detected along the way. However, if collateral injuries are slight, the entire diagnostic process is less invasive, so diaphragmatic injuries may pass unnoticed, particularly if they are not acutely life-threatening [12]. Neither initially, i.e., right after blunt trauma in a car accident, nor 26 years later were computed tomography (CT) or magnetic resonance imaging (MRI) performed, because this technology is not available at the General County Hospital of the City of Pozarevac, Serbia and Montenegro. Thus, laparoscopy proved to be the most reliable diagnostic method in those circumstances, a procedure suggested by other authors as well [10]. Roentgenography and roentgenoscopy performed 6 months after the operation showed reexpansion of pulmonary tissue. Satisfactory motion, i.e., excursions of the right hemidiaphragm, indicated proper functioning of diaphragm and phrenic nerve. The patient is now considered to be cured and in good overall condition. In this case, the direct impact of an oncoming vehicle into the passenger’s side resulted in the violent discharge of the driver from the automobile and a subsequently diagnosed series of rib fractures. This suggests that the real mechanism of hepatothorax was a sudden increase in intraabdominal tension, combined with deformation of the torso. We feel this case illustrates an unusually long development of progressive hepatothorax, accompanied by herniation of a portion of the stomach in the right half of the thorax, with symptoms being almost completely absent for 26 years. The only severe trauma that could have caused the rupture of the right hemidiaphragm was the car accident 26 years before. In short, this paper suggests that it is possible to determine the connection between injury and its consequences after a very long period of time.

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Address for Correspondence Tatjana Popovic, MD Ul. Ilije Bircanina 21 12 000 Pozarevac Serbia and Montenegro Phone (+381/12) 551918, Fax 212803 e-mail: [email protected]
