Asian Journal of Case Reports in Surgery

Aims: To describe the diagnosis, evaluation and management of a case of acute traumatic diaphragmatic hernia (TDH) with gut gangrene.

Presentation of the Case: A 36-year-old male presented with a history of road traffic accident and complaints of right hip dislocation, fractured femur and breathlessness. X-rays showed a massive left pleural effusion. CT abdomen was done and showed left TDH. Intercostal drainage tube was inserted and showed feco-bilious contents. Bowel perforation was suspected and patient taken up for emergency laparotomy. Intra-operatively, stomach and small bowel were seen herniating into the left thoracic cavity. A gangrenous patch was noted on the anterior wall of stomach with perforation, which was excised and repaired. A mesenteric tear was noted along with gangrene of terminal ileum. The gangrenous segment was resected and end-to-end anastomosis done. Thorough lavage was given and a diversion ileostomy made. The patient had a difficult postoperative period with severe sepsis, but recovered well and discharged on day 15.

Discussion: TDH is usually diagnosed late in patients of traumatic diaphragmatic rupture and can be life threatening. TDH in acute cases generally have subclinical evisceration which is frequently missed. We present an unusual case of acute TDH with gut gangrene which was managed by emergency surgery. Prompt intervention, insertion of ICD tube and a broad spectrum antibiotic cover helped manage the case and prevent mortality. 

Conclusion: A high degree of clinical suspicion is of prime importance in polytrauma cases to rule out traumatic diaphragmatic rupture with hernia. Early diagnosis and aggressive treatment can prevent mortality and improve outcomes.