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Post-traumatic
diaphragmatic rupture is an uncommon condition. This diaphragmatic breach can
create a hernia of the abdominal viscera under the effect of intrathoracic or abdominal
pressure. The clinical signs of this condition are non-specific and may
simulate other conditions. We report a case of left diaphragmatic hernia
simulating pneumothorax.
Observation:
Mrs. SA 38 years
old is admitted to resuscitation 24 h after a public road accident for acute
respiratory distress syndrome.
Upon
admission, the clinical examination revealed a clinical anemia, a closed
fracture of the right humerus, a polypnea with intercostal and suprasternal
circulation and a gaseous pleural effusion syndrome.
The
diagnosis of a pneumothorax is made and thoracic drainage is carried out
urgently.
In view
of the persistence of respiratory distress and the failure of thoracic
drainage, a chest scanner is carried out and concluded to a left diaphragmatic
rupture with ascent of the handles and spleen in the thorax. The indication of
a laparotomy is placed and carried out then the patient transferred in
digestive surgery to post-operative J4.
Conclusion:
Diaphragmatic ruptures remain serious lesions with high morbidity and
mortality. The diagnosis can sometimes be difficult to establish because the
signs are non-specific. The chest scanner currently makes it easy and fast to
make the positive and differential diagnosis of diaphragmatic rupture.
Keywords: Diaphragm rupture, Trauma, Pneumothorax, Computed
tomography
INTRODUCTION
Traumatic diaphragmatic rupture is defined as
a continuity solution involving the three tunics of the diaphragm. It can
deliver passage to the abdominal viscera attracted by chest aspiration. In a
traumatic context, diagnosis can sometimes be difficult to establish because
clinical signs can simulate other affections.
We report a case of left diaphragmatic
rupture with ascension of the colon in the thorax reminiscent of a
pneumothorax. We want to emphasize through this clinical case the importance of
computed tomography in the lesional balance of any polytraumatized.
OBSERVATION
Mrs. SA 38 years old is admitted to intensive
care unit 24 h after an accident of the public road for acute respiratory
distress. Upon admission the clinical examination highlights:
·
Clinical
anemia, normal consciousness.
·
TA
at 120/80 mm hg, FC at 98 beats/mn.
·
Polypnea
at 24 cycles/mn with flutter of the nose wings, intercostal pull, SPO2 at 92%
in ambient air.
·
Left
gaseous pleural effusion syndrome.
A closed fracture of
the left arm
An ex-sufflation puncture is performed
urgently that brings air without amendment respiratory distress.
The hypothesis of a post-traumatic
diaphragmatic hernia was established and confirmed by the chest scanner (Figures 2 and 3).
The patient is admitted to surgery for an
emergency laparotomy. Perioperative exploration allowed to objectivate a left diaphragmatic
tear greater than 10 cm (Figure 4)
with ascent of the left colic angle, transverse, epiploon and spleen in the
thorax. In addition there was also a capsular lesion of the spleen with
spontaneous hemostasis by thrombus. There was no perforation of the viscera. The
gestures made were a reintegration of the viscera into the abdominal cavity
with diaphragm print. The post-op suites were simple. At post-operative J2
after a normal radiographic check (Figure
5), the patient is transferred to post-operative visceral surgery at J4.
DISCUSSION
The incidence of
post-traumatic diaphragmatic rupture is fairly low in recent studies (from 1.2%
to 5%, up to 16.2%) [1]. The main etiology of ruptures of the diaphragm is
represented by road accidents (80%) [2]. The mechanism of occurrence would be
indirect, explained by a sudden increase in the trans-diaphragmatic pressure
gradient by intra-abdominal hyper pressure during trauma [2,3].
In our case, the
break-up was on the left, the most common form representing more than 65% of
the cases in the literature. The bilateral break is exceptional. On the right,
the liver acts as a buffer, the left hemidiaphragm being weakened by the
presence of the hiatal orifice and the lombo-costa trigone [4].
Diagnosis of
diaphragm rupture is often delayed and difficult because clinical signs are
inconsistent and non-specific. An unrecognized rupture can be very late, up to
50 years after the trauma, either through imaging for another pattern, or
through non-specific epigastric or thoracic pain. More rarely, it is discovered
during strangulation [5]. Diagnosis occurs in 20 to 40% of cases during
laparotomy performed for another lesion [6]. However, it can be evoked at an
early stage in front of early indications: digestive (abdominal pain,
vomiting), respiratory (chest pain, dyspnea, cough) and more rarely cardiac
(palpitations, pseudoangina pain) [7].
In the case of our patient, the respiratory signs were
at the forefront with dyspnea and gaseous pleural effusion syndrome. This made
us think of a pneumothorax, main differential diagnosis that could lead to
chest drainage with risk of perforation of the viscera.
At the paraclinical level, chest X-ray has a relatively
low sensitivity, but remains a screening tool with suggestive diagnostic
results only in 17-40% of patients [8]: A large aerial image or multiple aerial
images from the left base pushing the lung upwards and the mediastinum to the
right are very characteristic. Ascended handles can look like a pneumothorax.
The fine-cut abdominal chest scanner, allowing for coronal and sagittal
reconstructions is the reference examination for recent and old ruptures. It
recognizes 80% of left and 50% of right failures [9]. The most relevant
scannographic signs are the intrathoracic migration of digestive structures,
the sign of the neck, corresponding to the impression of diaphragmatic rupture
on the herniated organ, the “dependent-viscera sign”, corresponding to the contact
of an intra-abdominal organ with the posterior pleura in the absence of a
diaphragmatic boundary and finally the discontinuity of the diaphragm [10-12].
Treatment of
diaphragm rupture is surgical. This is an emergency when Ascended organs cause
respiratory problems.
The approach was
abdominal. This is the reference route for emergency surgeries. It allows the
exploration and treatment of abdominal viscera [9].
The evolution in
our case has been favorable. Mortality is most often related to associated
lesions and delay in management that promotes complications [13,14].
CONCLUSION
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