by: Richard Byrne M.D.
HPI:
- 22 yo male hx of prior GSW to L chest with retained bullet presents with chief complaint of 2 days of left sided chest and left upper quadrant abdominal pain, along with intermittent nonbilious emesis
- No fevers, no dyspnea, normal bowel movements
Physical Exam
- VS: T 97.3 HR 80 BP 153/70 O2 98% on RA
- Well appearing, in no distress
- Lungs clear bilaterally, heart sounds normal
- Abdomen soft, +tenderness in LUQ without guarding and rebound tenderness
- No lower extremity edema
ECG:
Chest film:
Interpretation: Apparent left sided pleural effusion, not apparent on lateral view
CT chest:
Highlighted area indicates diaphragmatic hernia with portion of the stomach in the left chest
Clinical Course
- NGT placed to decompress stomach
- Admitted to CT surgery
- Had EGD to assess viability of gastric mucosa which was normal
- Underwent open surgical repair of diphragmatic hernia with reduction of stomach into abdominal cavity
Pearls
- Diaphragmatic hernia is a rare condition usually a sequelae of trauma
- Conventional imaging such as CT will likely not detect an acute injury to the diphragm
- Patients often present late after acute trauma when visceral contents herniate into the chest cavity
- Exam may demonstrate acute respiratory distress and bowel sounds on pulmonary auscultation
- Patients may be in frank shock from gastric/intestinal ischemia
- Treatment is surgical, usually cardiothoracic
