Incarcerated diaphragmatic hernia presenting as gastric outlet obstruction

November 8, 2007
Surgical Rounds, November 2007, Volume 0, Issue 0

Rama Mulukutla, Surgical Resident I, Department of Surgery; Leila Green, Surgical Resident I, Department of Surgery; Anthony C. Disher, Professor and Chair, Department of Radiology; Derrick J. Beech, Professor and Chair, Department of Surgery, Meharry Medical College, Nashville, TN

Raama Mulukutla, MD

Surgical Resident I

Department of Surgery

Leila Green, MD

Surgical Resident I

Department of Surgery

Anthony C. Disher, MD

Professor and Chair

Department of Radiology

Derrick J. Beech, MD

Professor and Chair

Department of Surgery

Meharry Medical College

Nashville, TN

Introduction: Gastric outlet obstruction results when any disease, benign or malignant, mechanically impedes gastric emptying. Hernias are a benign cause of this condition and should be considered in any patient who presents with gastric outlet obstruction, especially if the patient has a history of trauma.

Results and discussion: This paper describes the case of a patient who was seen emergently for acute gastric outlet obstruction. The patient initially reported no history of trauma, but further questioning revealed he had been struck by a vehicle, resulting in hospitalization 4 years earlier. Computed tomography scans showed herniation of the stomach, intra-abdominal mesentery, and loops of bowel into the left hemithorax to the level of the left hilum. This paper discusses the evaluation and management of occult diaphragmatic rupture that manifests as gastric outlet obstruction.

Conclusion: Diaphragmatic hernias can result from trauma and may manifest years after the initial injury. Radiography plays a key role in diagnosis, and prompt surgical treatment is warranted to prevent gastric necrosis.

Gastric outlet obstructions can result from periesophageal hernias, frequently in association with gastric volvulus, and have also been reported in association with congenital diaphragmatic hernias. Acute gastric outlet obstructions usually result from progressive gastric intraluminal pathology. Acute gastric incarceration and obstruction associated with a noncongenital diaphragmatic hernia is rare. Most patients present with protracted nausea and emesis, which is usually nonbilious and results from pyloric obstruction secondary to progressive peptic ulcer disease or malignancy.

Case report

A 47-year-old man presented to the emergency department describing a 4-day history of intractable nonbilious vomiting. He reported sharp midepigastric pain that radiated to the left upper quadrant of his abdomen. He noted no recent constipation, fever, chills, hematemesis, or weight loss, but stated that his symptoms had progressed to complete dysphagia to solids and liquids. Although initially he reported no recent trauma, further questioning revealed he had been involved in a motor vehicle accident approximately 4 years earlier. The patient's surgical history included an appendectomy 1 year before his current presentation, at which time the radiographic findings showed an elevated left hemidiaphragm. He reported smoking between one and one-and-a-half packs of cigarettes daily.

Upon physical examination, the patient was in acute distress because of his abdominal pain. His sclerae were anicteric, and his mucous membranes were dry. He had a normal cardiac rate and rhythm, and there were no murmurs or gallops. Auscultation of his lungs demonstrated asymmetric breath sounds that significantly diminished as the left lung filled. His abdomen was soft and nondistended, with left upper quadrant tenderness elicited on palpation. There was no evidence of rebound tenderness or guarding. His bowel sounds were decreased. Rectal examination demonstrated normal sphincter tone and no rectal masses. His stool was guaiac-negative.

Initial management included nasogastric tube decompression and fluid resuscitation. An abdominal and chest radiograph showed evidence of a coiled nasogastric tube in the left upper quadrant of the abdomen and left lower hemithorax (Figure 1). Abdominal and pelvic computed tomography (CT) scans showed herniation of the stomach, intra-abdominal mesentery, and loops of bowel into the left hemithorax to the level of the left hilum (Figure 2).

The patient underwent an emergency exploratory laparoscopy. Diagnostic laparoscopy showed a 5 x 5-cm posterior lateral diaphragmatic defect (Figure 3). This warranted conversion to open laparotomy to repair the defect. The incarcerated stomach, spleen, and splenic flexure of the colon were reduced into the abdominal cavity, and primary repair or the diaphragmatic defect was performed.

The patient had an uneventful recovery. The thoracostomy tube was removed on postoperative day 3, and the patient was discharged from the hospital on postoperative day 5.

Discussion

Diaphragmatic rupture can present in the acute setting or, in the case of our patient, in a chronic form. In the acute setting, immediate massive herniation of the intra-abdominal contents through the defect can cause marked respiratory distress and gastric outlet obstruction. Herniated abdominal viscera can be confirmed radiographically by identifying loops of bowl in the thoracic cavity or finding the nasogastric tube coiled in the thorax on chest radiographs. Chronic diaphragmatic hernias may go unrecognized at the time of the initial injury and appear on radiographs as elevations of the hemidiaphragm or as irregularities in the diaphragmatic contour. These hernias may have a delayed presentation and not surface until many decades after the initial injury.1 Diaphragmatic hernias become evident as organs pass insidiously through the tear, ultimately becoming obstructed or producing respiratory compromise.2

Diaphragmatic hernias are managed with operative repair. A patient's prognosis depends on the size of the hernia and extent of damage to the affected organs in chronic cases. These injuries can be repaired using a transthoracic or transabdominal approach. In cases of large defects, repair may require mesh, typically nonabsorbable polytetrafluoroethylene mesh.

Acute gastric outlet obstruction usually results from progressive intraluminal pathology, such as peptic ulcer disease or malignancy. Gastric outlet obstructions can also occur due to periesophageal hernias with associated gastric vovulus. Delayed herniation of the stomach through a trauma-induced defect in the left hemidiaphragm can be an unsuspected cause of gastric outlet obstruction.

Diaphragmatic injuries may be missed in the acute setting, particularly if the tears are right-sided or when a solid organ such as the spleen (as opposed to the small or large bowel) has herniated.3 When prompted, our patient recounted a history of being struck by a low-speed motor vehicle 4 years earlier, which had resulted in hospitalization. A diaphragmatic lesion was not diagnosed at that time, but it could have been missed. Traumatic tears in the diaphragm are approximately 10 to 15 cm in diameter, and smaller tears may not lead to immediate signs of herniation.3,4 Four years after the initial trauma, our patient presented with a 5-cm defect. Chest radiographs may not detect diaphragmatic injuries, and diagnosis may hinge on the use of CT scanning, which is more sensitive in identifying these injuries.

Subtle findings, such as an elevated hemidiaphragm, may be the only indicators of a possible tear. An elevated hemidiaphragm, however, is a nonspecific finding and can result from multiple etiologies, such as phrenic nerve injuries, subdiaphragmatic abscesses, or atelectasis. Another radiographic finding suggestive of a diaphragmatic injury is the "collar sign," a waist-like construction of herniated bowel. Although this sign has 100% specificity for detecting herniated bowel, it has only 55% sensitivity on abdominal CT scanning.3

Traumatic rupture of the diaphragm with gastric outlet obstruction is relatively rare and occurs in only 3% to 7% of patients who suffer abdominal or thoracic trauma.4 Ninety percent of diaphragmatic ruptures occur on the left hemidiaphragm, primarily because of the protective effect the liver has on the right hemidiaphragm and possibly because of the under-diagnosis of right-sided injuries.5

Conclusion

Our case report illustrates the clinical management of a patient with an incarcerated stomach resulting from a traumatic diaphragmatic rupture. Diagnosis relies heavily on radiographic studies, including CT scanning. Operative management typically requires a transthoracic or transabdominal approach. A patient's prognosis depends on the size of the diaphragmatic defect and whether there is damage to associated organs. Early diagnosis and urgent management are critical for reducing the likelihood of gastric necrosis.

Disclosure

The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.

References

  1. Lobb TR, Butlin GR. Anaesthesia and traumatic diaphragmatic hernia. Can Anaesth Soc J. 1974;21(2):173-180.
  2. Cameron EW, Mirvis SE. Ruptured hemidiaphragm: unusual late presentation. J Emerg Med. 1996;14(1):53-58.
  3. Ball T, McCrory R, Smith JO, et al. Traumatic diaphragmatic hernia: errors in diagnosis. AJR Am J Roentgenol. 1982;138(4):633-637.
  4. Fleyfel M, Ferreira JF, Gonzalez de Linares H, et al. Cardiac tamponade after intrapericardial diaphragmatic hernia. Br J Anaesth. 1994;73(2):249-251.
  5. Agrawal KB, Kamble RT, Sundaram P, et al. The collar sign. Postgrad Med J. 2000;76(891):53-55.

Self-assessment questions

  1. All of the following may result in a ruptured?diaphragm, except: Avulsion of the diaphragm from its points of attachment Shearing of a stretched diaphragmatic?membrane Sudden transmission of force from the?viscera, which acts as a viscous fluid Increased intrathoracic pressure
  2. The most common presentation of traumatic diaphragmatic hernias includes: Elevated right-sided hemidiaphragm Elevated?left-sided hemidiaphragm Right-sided pneumothorax Left-sided pneumothorax
  3. Eventration of the diaphragm refers to: Congenital defect in the diaphragm Traumatic defect in the diaphragm The evisceration of bowel into the pleural cavity Abnormal elevation of the leaf of an intact diaphragm
  4. The most common cause of acquired diaphragmatic hernia is: Blunt trauma Penetrating trauma Phrenic nerve palsy Atelectasis

Read the Answers

Self-assessment answers

1. d?Increased intrathoracic pressure is not a cause of diaphragmatic rupture.

2. b?Most traumatic diaphragmatic hernias present with an elevated left-sided hemidiaphragm because 90% of all diaphragmatic ruptures occur on the left hemidiaphragm. This is attributed to the protective effect of the liver on the right hemidiaphragm and the possible underdiagnosis of right-sided injuries.

3. d?An eventration of the diaphragm refers to a continuously elevated diaphragm, which is an abnormal finding. The lack of a defect differentiates this condition from a diaphragmatic hernia.

4. a?Blunt trauma accounts for 75% to 81% of acquired diaphragmatic hernia cases.*

Reference

Ann R Coll Surg Engl.

* Simpson J, Lobo DN, Shah AB, et al. Traumatic diaphragmatic rupture: associated injuries and outcome. 2000;82(2):97-100.


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