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Missed diagnosis of a delayed diaphragmatic hernia as intestinal obstruction: a case report
Abstract:
Penetrating diaphragmatic injury rarely occurs in isolation. Diagnosis of traumatic diaphragmatic hernia resulting from penetrating diaphragmatic injury may be delayed or missed with attendant high morbidity and mortality. We reported a 28-year-old man who presented with features of subacute intestinal obstruction which became severe over the last four days. He had a stab injury to his left lower chest wall that was sutured 31/2 years prior to the development of symptoms. Emergency laparotomy with incidental findings of missed diaphragmatic hernia with gangrenous jejunal segment was found. The hernia was reduced, gangrenous segment resected with end to end anastomosis, and repair of diaphragmatic rent done. He had an uneventful recovery and follow up. There is the need to maintain high index of suspicion of Traumatic Diaphragmatic Hernia (TDH) in a patient with recent or previous thoraco-abdominal injury that will reduce the rate of missed or delayed diagnosis.
Insights
A delayed diagnosis of traumatic diaphragmatic hernia (TDH) following penetrating chest injury can lead to severe complications. Early suspicion and diagnosis are crucial for better patient outcomes.
Area of Science:
- Trauma Surgery
- Surgical Gastroenterology
- Thoracic Surgery
Background:
- Penetrating diaphragmatic injuries are often associated with other injuries, complicating diagnosis.
- Traumatic diaphragmatic hernias (TDH) can present insidiously, leading to delayed or missed diagnoses.
- Missed TDH is linked to significant morbidity and mortality.
Observation:
- A 28-year-old male presented with symptoms of subacute intestinal obstruction, worsening over four days.
- The patient had a history of a stab wound to the left lower chest wall, sutured 3.5 years prior.
- Emergency laparotomy revealed a missed diaphragmatic hernia with a gangrenous segment of the jejunum.
Findings:
- Surgical repair involved reducing the hernia, resecting the gangrenous jejunum with end-to-end anastomosis, and repairing the diaphragmatic rent.
- The patient experienced an uneventful recovery and follow-up.
- This case highlights the potential for delayed presentation of TDH.
Implications:
- Maintaining a high index of suspicion for TDH in patients with thoraco-abdominal trauma is essential.
- Prompt diagnosis and management of TDH can prevent severe complications like intestinal gangrene.
- This case underscores the importance of considering diaphragmatic injury in the long-term follow-up of chest trauma patients.
