Hrev_master [Emergency Care Journal 2016; 12:5892] [page 73] An unusual abdominal pain in the emergency department: a delayed presentation of diaphragmatic injury Ciro Paolillo, Valentina Siragusa Emergency Department, Udine University Hospital, Udine, Italy Abstract We present a case of delayed traumatic diaphragma rupture. The patient complained of a vague abdominal pain and left shoulder pain. Only the relevance of a remote trauma aroused the suspicion. Introduction The most common cause of diaphragmatic injury is a direct blow to the upper abdomen or lower chest. It is unusual after penetrating injuries such as a knife or bullet wound. The forces transmitted to the abdomen by blunt trauma can create a pressure gradient across the diaphragm of up to 1000 cm H2O, which may be sufficient to cause diaphragmatic injury and hence herniation of abdominal con- tents. The left side of the diaphragm is more prone to injury because it is not protected by the liver. Kelly1 reported that right sided ruptures are less frequent because they are associated with higher prehospital mortality; this likelihood decreases the number of surviving trauma vic- tims with right sided diaphragmatic injuries. Herniated organs generally include stomach, small bowel, colon, spleen and liver. In 1974, Grimes2 described the three phases of the rupture of the diaphragm based on time, after forty years this is still the most useful classification. The acute phase starts at the time of injury. Blunt, high velocity trauma increases the gradient between the abdominal compartment and the thorax, causing avulsion of the diaphragm from its point of attachment. If the diaphragmatic injury is not recognised during the immediate post traumatic period, then the patient progresses into the latent phase, characterized by intermittent visceral herniation of any abdominal structure due to the defect. Sometimes, the patient remains asymptomatic, and, sometimes patients com- plain of intermittent or nonspecific symptoms, nausea, vomiting, belching and vague post- prandial abdominal pain that is better with sit- ting or standing. The obstructive phase begins when the herniated abdominal organs becomes incarcerated. The patient complains of dyspnea, acute abdominal pain and vomit- ing. If not immediately treated the conse- quences can be catastrophic. Despite technological advances, a delay in diagnosis is common. Wallack in 20103 report- ed that 30-50% of traumatic diaphragmatic ruptures are missed on initial presentation. Case Report A 62-year-old man, presented to the ED com- plaining of abdominal pain. The patient was afebrile, his blood pressure was 120/80, respi- ratory rate was 18, heart rate was 90 and the oxygen saturation at room’s air was 95%. He reported a moderate pain in his left abdomen. The abdomen was soft, not were tender nor distended. Physical examination and ECG were normal. The biochemistry revealed a mild increase of white blood cells (11,000 cells/mmc) and C-Reactive Protein 7 mg/dL. Hepatic, pancreatic and renal parameters where within the normal limits. Clinical ultra- sound evidenced a normal abdominal aorta and a left renal image, no free fluid was pres- ent. It looked like a case of aspecific abdominal pain. After 3 mg of morphine the patient was brought in Radiology. Antero-posterior (AP) and lateral chest X-ray showed an air fluid level that obscured the left diaphragm (Figures 1 and 2). There was not mediastinal shift. The abdominal X-ray was normal. After a couple of hours the patient felt better and his pain has lowered. The ongoing physician reviewed the past clinical history. The patient reported a motor vehicle accident dating four months. He had thoracoabdominal trauma with a small pneumothorax (PNX) and several broken ribs on the left side. At the time thoracoabdominal computerised tomography (CT) denied a diaphragmatic rupture. He then reported occa- sional pain in his left shoulder and rare episode of shortness of breath. The urgent thoracoabdominal CT with iv- contrast evidenced a large breach of the diaphragm with intrathoracic organ displace- ment. Herniation involved the stomach, spleen, bowel and pancreas (Figure 3). The next day the patient underwent a surgi- cal reduction of the herniated organs, there was no ischemia and the diaphragmatic dis- ruption was repaired. Five days later the patient was discharged home. Discussion It is very difficult, if not impossible, to ascer- tain the true incidence of delayed diaphrag- matic injury. Road traffic collisions are the most frequent causes of acquired diaphrag- matic hernia, usually direct impact depresses the side of the rib cage, and can cause a tear in the diaphragm rib attachments, and even the transverse rupture of the diaphragm. In some cases acute diaphragmatic lacerations are repaired immediately, in other they are not recognised only to become apparent in the future, and some will never be detected. A delay in presentation could be explained by various different hypotheses: specific signs and symptoms may not be present during the acute phase, traumatic diaphragmatic tears are difficult to detect until there is herniation of intra-abdominal structure into the thorax. The development of symptomatic delayed diaphragmatic hernia can be a physiological consequence of the negative pressure in the chest that pulls intraabdominal contents through the diaphragmatic defect, while posi- tive intraabdominal pressure presses these contents in the same direction. Almost 88% of the patients with delayed diaphragmatic rup- ture presented with complications between 9 and 12 months after trauma. Singh4 reported a diaphragmatic rupture presenting 50 years after the traumatic event. Unfortunately the physical examination is often not helpful. In the latent phase clinical exam will either be entirely normal, or there will be subtle signs. A delayed rupture may be asymptomatic or pro- duce only mild, nonspecific symptoms, such as vague abdominal pain, chest or shoulder pain or recurrent dyspnoea for months or years. Pain may worsen with meals, it can be mistak- en for peptic ulcer disease, or pain may radiate to the left shoulder, a symptom that can be mis- taken for myocardial ischemia. Physical signs are of little aid unless the diagnosis is suspected, and usually only in ret- rospect the signs and the physical findings can Emergency Care Journal 2016; volume 12:5892 Correspondence: Ciro Paolillo, Emergency Department, Udine University Hospital, piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy. Tel: +39.0432.552360. E-mail: ciropaolillo@gmail.com Key words: Abdominal pain; Thoracic trauma; Diaphragmatic injury. Received for publication: 20 March 2016. Revision received: 1 July 2016. Accepted for publication: 4 July 2016. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright C. Paolillo and V. Siragusa, 2016 Licensee PAGEPress, Italy Emergency Care Journal 2016; 12:5892 doi:10.4081/ecj.2016.5892 Non co mmerc ial us e o nly be related. Traumatic diaphragmatic hernias represent a diagnostic challenge not only clin- ically but also radiographically. Despite techni- cal limitations, chest radiography is still used as the first step for the detection of diaphrag- matic injury. Adeguate visualisation of the diaphragm can be difficult because it is thin, has a domed contour, and is contagious with soft tissue of the abdomen. Intrathoracic air in a silhouette consistent with supra-diaphrag- matic viscera may occur in up to 50% of patients with left-sided diaphragmatic hernia- tion. Murray in 19985 reported that 62% of the patients with acute diaphragmatic injuries had a normal chest radiograph at the time of injury. Nau6 showed that only 25 to 49% of initial chest X rays were of diagnostic value. Frequently, a herniation at the costophrenic angle may be misdiagnosed as a pleural effu- sion or haemothorax on the chest radiography. As these findings are nonspecific, the trauma history in combination with unexplained radi- ographic findings should lead to a prompt CT. The most common findings on CT include a localised defect of the diaphragm, the absent diaphragm sign, and herniation of hollow organs into the hemithorax. Grillo in 2000,7 reported that the sensitivity of a conventional CT scan detecting traumatic diaphragmatic injury ranges between 14 and 82% while speci- ficity ranges between 76 and 100%. Accuracy is augmented if there is a herniation of the intra- abdominal contents. Conclusions Delayed diaphragmatic injury is a diagnos- tic challenge. The ability to make the diagnosis has somewhat improved because of the tech- nologic advances in CT, however, it remains true that the best tool to guide the clinician toward the appropriate diagnosis is a high index of suspicion whenever there is a history of high velocity trauma, regardless of how remote, and particularly when other signs of severe trauma were present at time of injury. The morbidity and mortality of surgical inter- vention increases dramatically in patients pre- senting with acute obstructive symptoms from delayed diaphragmatic injury, whereby the need to pursue the diagnosis if there is the suspect. References 1. Kelly J, Condon ET, Kirwan WO, Redmond HP. Post-traumatic tension faecopneu- mothorax in a young male: case report. World J Emerg Surg 2008;3:20. 2. Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am J Surg 1974;128:175-81. 3. Walchalk LR, Stanfield SC. Delayed pres- entation of traumatic diaphragmatic rup- ture. J Emerg Med 2010;39:21-4. 4. Singh S, Kalan MM, MOreyra CE, Buckman RF. Diaphragmatic rupture pre- senting 50 years after the traumatic event. J Trauma 2000:49:156-9. 5. Murray JA, Berne J, Asensio JA. Penetrating thoracoabdominal trauma. Emerg Med Clin North Am 1998;16:107-28. 6. Nau T, Seltz H, Mousavi M, Vecsei V. The diagnostic dilemma of traumatic rupture of the diaphragm. Surg Endosc 2001;15:9 92-6. 7. Grillo IA, Jataniah SA, Bayoumi AH, et al. Traumatic diaphragmatic hernia: an Asir region (Saudi Arabia) experience. Indian J Chest Dis Allied Sci 2000;42:9-14. Case Report Figure 1. Anteroposterior chest X-ray on presentation (note the presence of air fluid level at the left lung base). Figure 2. Latero-lateral chest X-ray. Figure 3. Coronal computed tomography scan showing disrupted left hemidi- aphragm. [page 74] [Emergency Care Journal 2016; 12:5892] Non co mmerc ial us e o nly