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  • • May be acute or chronic following either penetrating or blunt trauma

    • -Acute form associated with respiratory distress

      -Chronic form marked by pain and bowel obstruction

    • Chest film showing NG tube, air fluid level, or abdominal vicera in the chest is diagnostic

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Epidemiology

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  • • Traumatic rupture of the diaphragm may occur as a result of penetrating wounds or severe blunt external trauma

    • Lacerations usually occur in the tendinous portion of the diaphragm, most often on the left side

    • Abdominal viscera may immediately herniate through the defect in the diaphragm into the pleural cavity (acute) or may gradually insinuate themselves into the thorax over a period of months or years (chronic)

    • In the acute form, the patient has recently experienced blunt trauma or a penetrating wound to the chest, abdomen, or back

    • In the chronic form, the diaphragmatic tear is unrecognized at the time of the original injury

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Symptoms and Signs

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  • • Acute herniation

    • -Symptoms from concomitant injuries

      -Respiratory insufficiency

    • Chronic herniation

    • -Pain

      -Bowel obstruction

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Imaging Findings

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  • Chest film: A radiopaque area and occasionally an air fluid level if hollow viscera have herniated

    • If the stomach has entered the chest, the abnormal path of an NG tube may be diagnostic

    US, CT scan, and MRI: Demonstrate the diaphragmatic rent

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  • • In an acute traumatic setting, focus attention on life-threatening injury

    • -Diaphragmatic herniation may be considered as a possible source of respiratory distress

    • In a patient with a history of abdominal trauma and a bowel obstruction, missed diaphragmatic hernia should be considered

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Rule Out

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  • • Atelectasis

    • Space-consuming tumors of the lower pleural space

    • Pleural effusion

    • Intestinal obstruction due to other causes

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  • • Chest film

    • CT scan

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When to Admit

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  • • All acute cases

    • Chronic cases with evidence of bowel obstruction, severe pain

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  • Acute: Repair after stabilized or at the same time as other injuries are treated if multiple injuries.

    Chronic

    • -Symptomatic, urgent repair

      -Asymptomatic, elective repair

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Surgery

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Indications

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  • • All diaphragmatic hernias should be repaired

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Complications

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  • • Respiratory insufficiency

    • Intestinal obstruction and perforation

    • Intestinal bleeding

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Prognosis

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  • • Excellent after surgical repair; very seldom recurrent

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References

Grover SB, Ratan SK. Simultaneous dual posttraumatic diaphragmatic and abdominal wall hernias. J Trauma. 2001;51:583.  [PubMed: 11535916]
Meyer G et al. Laparoscopic repair of traumatic diaphragmatic hernias. Surg Endosc. 2000;14:1010.  [PubMed: 11116407]

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