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* From the Department of Surgery, (Drs. Seelig and Klinger), Mayo Clinic Jacksonville, Jacksonville, FL; and the Department of Surgery (Dr. Schönleben), General Hospital Ludwigshafen, Ludwigshafen am Rhein, Germany.
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Abstract |
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Key Words: diaphragmatic hernia • pneumothorax • stab wound • surgical treatment
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Introduction |
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We report on a 20-year-old man with a tension pneumothorax resulting from an intrathoracic perforation of the colon into the chest after a penetrating stab wound and a traumatic diaphragmatic hernia.
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Case Report |
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Twelve days before the present admission, the patient was admitted to the hospital because of cramping epigastric pain. He was afebrile, and his physical examination was unremarkable. The WBC count was 15.7 x 109/L. An abdominal ultrasound revealed no pathology, and an upright abdominal radiograph was normal. The patient was put on IV fluids and observed. The pain disappeared over the next few days. An esophagogastroduodenoscopy demonstrated an axial hiatal hernia and grade 1 reflux esophagitis. Omeprazole was prescribed, and the patient was dismissed without complaints. Four days later he was readmitted as an emergency patient.
The patient was in acute distress with dyspnea and jugular venous distention, and he required oxygen. His respiratory rate was 30 beats/min, and his oxygen saturation as determined by pulse oxymetry was 90%. The BP was 100/70, and the pulse rate was 100 beats/min. A physical examination revealed no breath sounds in the left chest. An abdominal examination showed mild diffuse tenderness but no signs of peritonitis. Because a tension pneumothorax was suspected, a large-bore needle was inserted in the second left costal interspace. This maneuver stabilized the patient. Subsequently, a 20 Charriere chest tube (Mallinckrodt Medical; Athlone, Ireland) was inserted in the second left intercostal space, and 700 cm3 of feculent fluid was drained. A CT scan of the thorax demonstrated a portion of the large bowel in the left chest cavity (Fig 1 ). An esophagram could not confirm any leakage. A colonic enema with gastrografin revealed a colopleural fistula from the splenic flexure into the left thorax (Fig 2 ).
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Discussion |
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Blunt abdominal trauma and penetrating injuries through the abdomen or the chest involving the diaphragm are the main etiologic factors for traumatic diaphragmatic hernias. All cases of fecal pneumothorax resulting from diaphragmatic herniation and perforation of the colon share a uniform history of a stab wound to the chest. There is only one report of a tension pneumothorax because of a perforation of the small bowel after a blunt chest trauma and fracture of three ribs.11 Another common finding was delayed clinical presentation.
As long as no bowel is injured, a traumatic diaphragmatic hernia may easily be missed after a stab wound to the chest because of the lack of symptoms. The findings of a chest roentgenogram are often normal. However, the mechanism of the trauma, the level and angle of penetration, the physical findings, and the abnormal findings on the initial chest radiograph such as hydropneumothorax or an "elevated" diaphragm, as well as certain ultrasound findings (interruption of the diaphragm), may raise suspicion of a diaphragmatic hernia. Laparoscopy has recently been used to detect intra-abdominal injuries following penetrating thoracoabdominal traumatic injuries, and it has been proven to be an excellent tool for the detection of diaphragmatic injuries.12,13 Laparoscopic exploration at the time of the patient’s initial chest trauma may have prevented the subsequent incarceration. The importance of an early diagnosis of diaphragmatic herniation has recently been emphasized by Degiannis et al.14 In a retrospective study of 45 patients with diaphragmatic herniation after penetrating trauma, the diagnosis was established at the first admission in 29 patients; whereas, in 16 patients the diagnosis was delayed (with a median of 27 months). The mortality rate in the group with early presentation was 3% compared to 25% in the group with delayed presentation. The presence of a gangrenous or perforated stomach, or large bowel in the chest was the most common and aggravating factor.
The diagnosis of tension pneumothorax is usually based on clinical findings. The patient is in acute respiratory distress and is tachypneic, tachycardic, and possibly hypotensive. The jugular venous pressure is elevated when an upper-inflow obstruction caused by mediastinal deviation occurs. Breath sounds at the site of the injury are absent. In this urgent clinical setting, immediate relief is achieved by the insertion of a large-bore needle or by the insertion of a chest tube.
Feculent drainage from the chest tube is highly suspicious for the presence of a colopleural fistula. Prior to surgery, confirmation of the diagnosis should be achieved. A standard frontal chest radiograph should be obtained because it remains the most sensitive method for diagnosing a traumatic diaphragmatic injury.15 An upper-GI study with water-soluble contrast material may be necessary to exclude the possibility of an esophageal or gastric perforation. A CT scan or MRI may confirm the diagnosis or give additional information about the extent of the lesion.15 This is particularly helpful to exclude further fluid collections or abscesses. The simplest and most practical way to establish the diagnosis is by using a gastrografin enema. In our case, the connection between the splenic flexure and the pleural cavity was clearly visualized.
Immediate surgical repair is important. A laparotomy with resection of the incarcerated bowel, a transdiaphragmatic lavage, and the closure of the hernia may be one option. Alternatively, an initial thoracotomy may be performed, with the advantage of better exposure of the chest to achieve complete lavage. In six of nine cases reported in the literature, an immediate laparotomy was performed; whereas, in one report the type of treatment was not described. In only two cases, the initial procedure was a thoracotomy followed by a laparotomy to create a colostomy. 2,4 Postoperative pleural empyema occurred in one patient treated with an initial thoracotomy and in two patients who underwent a laparotomy.1,2,5 One patient died secondary to sepsis.9 A colectomy followed either by primary anastomosis or creation of a temporary colostomy should be performed. If only a laparotomy is performed, the pleural cavity should be lavaged with large amounts of fluid and the diaphragm closed by standard surgical techniques. However, pleural empyema may be an additional complication despite broad-spectrum antibiotic therapy that requires further surgical intervention.
Fecal pneumothorax is a potential complication following a posttraumatic diaphragmatic hernia resulting from a stab wound to the chest. This clinical finding should be included in the differential diagnosis of an atypical spontaneous pneumothorax, it should be confirmed by contrast studies, and it should be repaired without delay.
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Footnotes |
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Received for publication May 6, 1998. Accepted for publication July 15, 1998.
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This article has been cited by other articles:
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  L. Kotsis, A. Csekeo, K. Orban, and M. H. Seelig Latent Traumatic Diaphragmatic Hernia : A Surgical Challenge Chest, March 1, 2002; 121(3): 1006 - 1006. [Full Text] [PDF]
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R. Andrade-Alegre Chronic Diaphragmatic Hernia Chest, December 1, 1999; 116(6): 1838 - 1839. [Full Text] [PDF]
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