Diaphragmatic Hernia, Traumatic

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • Acute herniation

  • -Symptoms from concomitant injuries

    -Respiratory insufficiency

  • Chronic herniation

  • -Pain

    -Bowel obstruction

Imaging Findings

• • 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

• • 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

Rule Out

• • Atelectasis

  • Space-consuming tumors of the lower pleural space

  • Pleural effusion

  • Intestinal obstruction due to other causes

• • Chest film

  • CT scan

When to Admit

• • All acute cases

  • Chronic cases with evidence of bowel obstruction, severe pain

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

  • Chronic

  • -Symptomatic, urgent repair

    -Asymptomatic, elective repair

Surgery

Indications

• • All diaphragmatic hernias should be repaired

Complications

• • Respiratory insufficiency

  • Intestinal obstruction and perforation

  • Intestinal bleeding

Prognosis

• • Excellent after surgical repair; very seldom recurrent

References