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Prepared by Natali Carballo, Medical Student, and Brad Peckler, MD, Assistant Professor, Department of
Emergency Medicine, Tampa General Hospital, University of South Florida, Tampa
An 81-year-old man was rushed to the emergency department by ambulance after a syncopal episode following a bowel movement. He complained of abdominal pain that radiated to the thorax and back and reported feeling ill for the past several days, fatigue, and nonlocalized abdominal and back pain. He did not have emesis, chest pain, dyspnea, or recent trauma. His history included ischemic cardiomyopathy, congestive heart failure, mitral valve regurgitation, arthritis, hemorrhoids, a prolapsed rectum, an old hiatal hernia repair, and coronary artery bypass graft surgery performed a few years ago. Vital signs were: blood pressure, 97/59 mm Hg; pulse, 80 beats/min; respiration, 16 breaths/min. On physical examination, the abdomen was distended and rigid, with flanks of blue discoloration.
His chest radiograph (Figure 1) and a computed tomography (CT) scout film (Figure 2) are shown.
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| Figure 1 | Figure 2 |
What?s Your Diagnosis?
- Pneumothorax
- Ruptured esophagus
- Diaphragmatic hernia with bowel strangulation
- Pulmonary mass fever
Quiz Answer
Diaphragmatic hernia with bowel strangulation—The x-ray and CT scout film showed a massive right-sided diaphragmatic hernia (Figure 1), with evidence of bowel eventration and free air under the right diaphragm (Figure 2). A nasogastric tube was placed. The patient remained alert, oriented, and calm, but breathing required increased effort, and he became pale. Continued deterioration was expected, and rapid sequence intubation was performed. Immediately after intubation his blood pressure dropped to a pulseless 35/19 mm Hg. Life support was started, but resuscitative efforts were unsuccessful.
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| Figure 1 | Figure 2 |
Pneumothorax can be ruled out, since the lung is fully inflated, as seen on the radiograph. A ruptured esophagus would not explain the bowel seen in the right chest. No mass is seen in the lungs, only bowel.
Autopsy performed 4 days later revealed a 3.0 x 2.5-cm defect in the diaphragm adjacent to old suture material. Half of the stomach and 15 cm of the duodenum were herniated through the defect and into the chest cavity. The stomach was found to contain 20 mL of blood, with evidence of vascular congestion. A perforated gastric ulcer measuring 2.3 x 1.8 cm was noted adjacent to the diaphragmatic defect. Chemical peritonitis, approximately 500 mL of bloody fluid, and brown fecal material were noted within the peritoneal cavity. An additional 250 mL of brown fluid was found in each pleural cavity. No acute cardiac or pulmonary findings were reported.
Correct recognition and management of complicated and rare presentations of abdominal catastrophe in the elderly are important in the emergency department. Hernias and ulcers are not uncommon findings in the elderly population, but are considered exceptionally uncommon when paired with incarceration and perforation.1 The mortality rate is high in such cases; to our knowledge only 1 case has been reported with a successful outcome.2
Perforation should always be considered in the differential diagnosis of abdominal catastrophes. Because diaphragmatic hernias can remain asymptomatic for years, patients often present late, as a surgical emergency.1
Presentation can vary and does not always reflect the patient's condition. The typical patient is in the seventh or eighth decade of life, with many medical problems. Acute-onset abdominal pain (with or without vomiting) and dyspnea are typical complaints.
Our patient, however, presented a picture more similar to that of an acute abdominal aneurysm, with vague abdominal pain that radiated to the back, as well as recent syncope. Clinical findings also vary; 1 case report described a patient with a soft and nondistended abdomen, but with severe epigastric tenderness.2 Marked abdominal distension with diffuse tenderness was noted in 3 cases.3,4 It is also possible for patients to have no peritoneal signs.1
A plain chest x-ray should be obtained when physical examination findings do not contribute to the diagnosis. Subdiaphragmatic pneumoperitoneum is usually present, but in some case reports no free air was observed under the diaphragm.4 In one such case, the diagnosis was made by visualizing the hernia shadow on plain films.4 Emergent surgery remains the treatment of choice for perforated ulcers. Using a nasogastric tube to decompress the stomach may help prevent strangulation, as well as gain time until a team with surgical experience (above and below the diaphragm) can be assembled.2
References
- Otsuka Y, Nara S, Ito K, et al. Perforated duodenal ulcer associated with an incarcerated hiatal hernia. Surg Today. 2002;32:1085-1087.
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Ekelund M, Ribbe E, Willner J, et al. Perforated peptic duodenal ulcer in a paraesophageal hernia—a case report of a rare surgical emergency. BMC Surg. 2006;6:1.
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Maruyama T, Fukue M, Imamura F, et al. Incarcerated paraesophageal hernia associated with perforation of the fundus of the stomach. Surg Today. 2001;31:454-457.
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Rakic S, Hissink RJ, Schiff BW. Perforation of gastric ulcer associated with paraesophageal hernia causing diffuse peritonitis. Dig Surg. 2000;17:83-84.
