Grave thoraco-intestinal complication secondary to an undetected traumatic rupture of the diaphragm: a case report

Abstract

Background: Diaphragmatic lesions as a result of blunt or penetrating trauma are challenging to detect in the initial trauma setting. This is especially true when diaphragmatic trauma is part of a polytrauma. Complications of undetected diaphragmatic defects with incarcerating bowel are rare, but as in our patient can be serious.

Case presentation: A 57-year-old female presented to the Emergency Room of our Hospital in a critical condition with 3 days of increasing abdominal pain. The initial clinical examination showed peritonism with tinkling peristaltic bowel sounds of mechanical obstruction. A thoraco-abdominal CT scan demonstrated colon prolapsed through the left diaphragmatic center with a large sero-pneumothorax under tension. As the patient was hemodynamically increasingly unstable with developing septic shock, an emergency laparotomy was performed. After retraction of the left colon, which had herniated through a defect of the tendinous center of the left diaphragm and was perforated due to transmural ischemia, large amounts of feces and gas discharged from the left thorax. A left hemicolectomy resulting in a Hartmann-type procedure was performed. A fully established pleural empyema required meticulous debridement and lavage conducted via the 7-10 cm in diameter phrenic opening followed by a diaphragmatic defect reconstruction. Due to pneumonia and recurring pleural empyema redo-debridement of the left pleural space via thoracotomy were required. The patient was discharged on day 56. A thorough history of possible trauma revealed a bicycle-fall trauma 7 months prior to this hospitalization with a surgically stabilized fracture of the left femur and conservatively treated fractures of ribs 3-9 on the left side.

Conclusion: This is the first report on a primarily established empyema at the time of first surgical intervention for feco-pneumothorax secondary to delayed diagnosed diaphragmatic rupture following abdomino-thoracic blunt trauma with colic perforation into the pleural space, requiring repetitive surgical debridement in order to control local and systemic sepsis. Thorough investigation should always be undertaken in cases of blunt abdominal and thoracic trauma to exclude diaphragmatic injury in order to avoid post-traumatic complications.

Keywords: Bowel perforation; Case report; Diaphragmatic rupture; Herniation; Pleural empyema; Pneumothorax.

Fig. 1

Radiological imaging on day of admission. Thoraco-abdominal CT scan with localizer of carried out CT scan (a) and representative CT scan images (b, c): enterothorax with splenic flexure prolapse through an old undetected traumatic rupture of the left diaphragmatic center, consecutive colic incarceration (b + c; arrows) with ischemia, rupture of the colon into the left pleural cavity with feco-pneumothorax under tension, cardiac depression due to mediastinal shift to the right and sepsis secondary to left pleural empyema (c), inversed diaphragm and midline shift to the right (a + b). Post-surgical chest X-ray examination (d): re-expanded left lung and reversal of the mediastinal shift with reconstructed diaphragm

Fig. 2

Radiological imaging on day 20. Chest X-ray examination (a) and thoraco-abdominal CT scan (b): reaccumulation of the left pleural empyema. The diaphragm stayed intact (black arrows) over the whole clinical course subsequent to reconstruction during initial surgery on day 1. White arrows indicate remnants of the healed rib fractures as a consequence of the bicycle trauma 7 months prior to admission for feco-pneumothorax