Tension Pneumothorax due to Colon Perforation in Delay Post Traumatic Diaphragmatic Hernia: Case Report

Special Issue - Intensive Care

Austin Emerg Med. 2021; 7(1): 1070.

Tension Pneumothorax due to Colon Perforation in Delay Post Traumatic Diaphragmatic Hernia: Case Report

Samsami M, Tahmasbi H, Nikraftar P and Bagherpour JZ*

Department of Surgery, Shahid Beheshti University of Medical Sciences, Imam Hossein Hospital, Iran

*Corresponding author: Javad Zebarjadi Bagherpour, Department of General Surgery, Shahid Beheshti University of Medical Sciences, Imam Hossein Hospital, Shahid Madani Avenue, Imam Hossein Square, Tehran, Iran

Received: March 30, 2021; Accepted: April 22, 2021; Published: April 29, 2021

Abstract

Diaphragmatic injuries were described first by Sennertus in 1541. Rupture of the diaphragm due to blunt trauma is a rare event that is usually not detected in the acute phase of trauma and may manifest itself late and with dangerous complications. The common side effects of this injury include displacement of the abdominal viscera into the thoracic cavity, which can cause respiratory problems due to limited lungs. Abdominal organs such as stomach, omentum, intestines, spleen, and liver are the most common to herniate in to the thoracic cavity .In late presentation, the key point is to identify the patient’s strong clinical suspicion and history. CT scan is the most common modality in diagnosis of diaphragmatic hernia. In this article, we introduce a unique case of diaphragmatic hernia after trauma due to falling from a height of 2 years ago, which showed itself with a tension pneumothorax in its management.

Keywords: Diaphragmatic hernia; Complication; Trauma

Introduction

Diaphragmatic injury may occur due to both penetrating and blunt traumas [1]. The frequency with which either of these mechanisms leads to diaphragmatic injury varies according to the geographic location [2]. The incidence of post-traumatic blunt diaphragmatic injury varies from 0.16 to 5%. Up to 70% of diaphragmatic tears are missed initially [3]. The most common causes of diaphragmatic hernia due to blunt injuries include falling from a height and road accidents; rate of diaphragmatic hernia mortality varies from 5 to 51% [4].The common side effects of this injury include displacement of the abdominal viscera into the thoracic cavity, which can cause respiratory problems due to limited lungs. Other dangerous side effects include strangulation of viscera inside the thorax, which can be up to 70% mortality rate. Diaphragmatic hern diagnosis methods include chest x-ray, MRI, and CT scan, which is the most common modality [5]. Approximately 69% of traumatic hernias are left sided, 24% are right- sided and 15% are bilateral. Diaphragmatic hernia diagnosis miss in 56% of cases in the acute phase if it is asymptomatic [6]. High index of clinical suspicion is required because of the missed diagnosis and potential for delayed presentation. Here we introduce a case of diaphragmatic hernia after blunt trauma, which was referred with tension pneumothorax due to necrosis of the colon inside the thorax cavity.

Case Presentation

A 52-year-old male was admitted to the emergency department with fever and dyspnea from 2 days ago. Initially the vital sign was pulse rate = 110, respiratory rate = 32, oxygen saturation = 83%, Temperature = 38 and blood pressure = 130/70. In the patient’s history, there was a history of femoral fractures due to a fall from a height of 6 meters 2 years ago. At the CT-scan there was a pneumothorax in the left hemithorax with shifting mediastinum. And Findings in favor of diaphragmatic hernia (Figure 1A-1C). Chest tube was inserted in left hemithorax. After insertion, gas with fecal material was drained from chest tube. The patient transferred to operation room after resuscitation with diagnosis colonic perforation due to diaphragmatic hernia. At first midline laparotomy was done. Transverse colon was herniated to thorax from a defect about 3 centimeters in left side diaphragm. Colon extracted from diaphragm. There was a perforation in transverse colon about 5 centimeters from splenic flexure. Colon released from spleen and after refreshing the perforation margin a loop colestomy was done from perforation site. Then, posterolateral thoracotomy was done. There was fecaloid material in pleural space and peel on lung. Washing and decortication was done, two chest tubes were inserted, and patient transferred to surgical intensive care unit, and antibiotic therapy was performed with broad-spectrum antibiotics. To prevent abscess formation and re-infection, Thorax cavity washes through continuous thoracic tubes. After 4 days, the patient was transferred to the ward, and after ensuring that the lungs were completely expand, the chest tubes were removed (Figure 1C). On the 10th day after the operation, he was discharged from the hospital. Two months later, he underwent colostomy clouser and ao complications were found in 6 month follow up.