Incarcerated Diaphragmatic Hernia with Bowel Perforation Presenting as a Tension Pneumothorax
A 50-year-old female with a past medical history of hypertension, type 2 diabetes, gastroesophageal reflux disease, paraesophageal gastric hernia, diaphragmatic hernia, and sickle cell trait presented to the emergency department (ED) with acute onset left-sided pleuritic chest pain and severe dyspnea. Relevant past surgical history includes Nissen fundoplication and appendectomy. Upon her arrival she was hemodynamically unstable with a heart rate of 162 beats per minute, blood pressure 75/62, and respiratory rate of 36 per min. Her oxygen saturation was 98% on room air.\nThe patient was seen immediately. Upon initial examination she was noted to be in severe respiratory distress and could not speak more than one or two words between breaths. While attempting to obtain an initial history from the patient her BP began to drop further and she became more tachycardic. Monitor revealed continued sinus tachycardia with no ectopy. Upon auscultation it was noted that breath sounds were completely absent in the left hemithorax. Bedside ultrasound was immediately available and showed an abnormal pleural line, lack of comet-tail artifacts, and absence of lung sliding motion. This was felt to be consistent with pneumothorax. Due to her worsening cardiovascular instability it was decided that there was not sufficient time to obtain a portable chest radiograph and emergent needle thoracostomy was performed. After applying betadine solution to the overlying skin, a 14-gauge intravenous catheter was inserted in the left second rib interspace in the mid-clavicular line. Immediately a large release of air was appreciated. The patient’s BP increased from 63 systolic to 100 systolic and her heart rate began to decrease. Additionally, she was no longer exhibiting signs of respiratory distress as she was much less tachypneic and no longer using accessory muscles. The patient now demonstrated appreciable, however diminished, breath sounds on the left. Of note, this was the only intervention given to this patient at this time. At this point, the patient had not yet received any fluid resuscitation, vasoactive medications, nor antiarrhythmics.\nAt that point it was felt that the patient was stable enough to obtain a chest radiograph. The radiograph showed some residual pneumothorax but also showed what appeared to be bowel in the left hemithorax (). Lung markings could not be visualized 3 centimeters from the apex, although the exact size could not be determined due to overlying bowel. The radiologist’s report noted that the splenic flexure of the colon was herniated through the left hemidiaphragm. There was some aeration in the left upper lobe of the lung, the remainder of the left hemithorax was opacified. Cardiothoracic surgery was consulted, reviewed the chest radiograph and made the recommendation to replace the needle thoracostomy with a Heimlich valve to temporize the patient as we obtained an axial computed tomography (CT). After placing the Heimlich valve, a CT of the chest was obtained and showed a left diaphragmatic hernia with an intrathoracic loop of colon along with a loculated hydropneumothorax suspicious for empyema (). This was compared to a CT from 12 days prior when she presented to the ED with abdominal pain and vomiting. The previous scan showed no evidence of incarceration of the bowel loop or the presence of an empyema. She had been following the diaphragmatic hernia with a surgeon on an outpatient basis. On that visit, her symptoms resolved and was discharged. She returned 2 days prior to this presentation with posterior thoracic pain. At that time, chest radiograph was obtained and showed the known hernia but no acute process, specifically no pneumothorax. She was felt to have musculoskeletal pain and was once again discharged. However, the CT scan obtained on the current visit showed an increased amount of colon within the thorax and the colon appeared to be significantly more distended when compared to the prior CT. This was suspicious for incarceration of the colon.\nThe patient continued to remain hemodynamically stable while in the ED. Her surgeon that she was seeing regarding the diaphragmatic hernia was contacted and came to see her in the ED. Upon reviewing the radiograph and CT results, plans were made to take the patient to the operating room for an exploratory laparotomy. This revealed a 3.5 cm diaphragmatic defect approximately 3 cm lateral to the esophageal hiatus through which a 10 cm segment of transverse colon was incarcerated. The segment of incarcerated transverse colon appeared ischemic and there was a 2 mm perforation. General surgery could not reduce the hernia. Therefore, cardiothoracic was called in to perform a thoracotomy and radial incision of the diaphragm “because of the narrowness of the diaphragmatic hernia.” Bowel, as well as omentum, was found to be “edematous and matted,” and was reduced and passed into the abdomen. No frank pus or stool was observed in the thoracic or peritoneal cavities. The ischemic segment of bowel was resected to healthy colon both proximally and distally and a side-to-side anastomosis was created. A chest tube was inserted into the left posterior thoracic cavity and the diaphragmatic defect was repaired.\nCultures of serosanguineous secretion from the chest tube showed growth of Escherichia coli and Enterococcus Avium. She was placed on antibiotic therapy. She gradually regained bowel function and continued to improve quite well. She was discharged after a 9-day hospital stay in good condition.