Obstruction-strangulation of post-traumatic diaphragmatic hernia--delayed diagnosis and fatal outcome

The radiological and clinical features of 9 cases of obstructed post-traumatic diaphragmatic hernia are reviewed. In none of these patients was the diagnosis of a diaphragmatic hernia considered before radiography, all cases being clinically diagnosed as 'acute abdomen', most frequently pancreatitis or perforated peptic ulcer. Even after radiographs had shown opacity at the left base in all 9 cases, together with a distended proximal bowel in 6, the correct diagnosis was made in only 4. Through lack of correct radiological diagnosis, there was a delay of at least 1 day between admission and operation in 6 patients, and 3 of the 4 deaths occurred in this group. Obstruction-strangulation of diaphragmatic hernia should be considered as a possible cause of 'acute abdomen' in the presence of a left basal abnormality, especially in patients from areas with a high incidence of assault. Confirmatory contrast studies should be done only if they can be done immediately and quickly. Pregnancy can cause hernias to become obstructed and strangulated, but this can be averted by obtaining a history of previous trauma early in the pregnancy.