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Sudden chest pain two months after a motor vehicle accident

Published:April 29, 2016DOI:https://doi.org/10.1016/j.ejim.2016.04.008

      Highlights

      • Diaphragmatic rupture usually occurs following major trauma.
      • Delayed presentation of diaphragmatic rupture is either due to delayed detection or delayed rupture.
      • It should be suspected in cases with chest or abdominal pain after recent or remote trauma.

      1. Indication

      A 60-year-old-woman presented to the emergency department with a six-hour history of severe left pectoral chest pain radiating to left shoulder associated with shortness of breath. She noted that these symptoms improve with upright position and worsens with laying supine. Electrocardiogram and serial cardiac enzymes were normal. Chest X-ray revealed a dilated stomach protruding into the left chest (Figure 1, panel a) that was not present in chest X-ray that had been performed 3 months earlier (Figure 1, panel b). Computed tomography scan of the chest also confirmed protrusion of the stomach into the left chest (Figure 1, panel c, d). Two months earlier, the patient had suffered from a motor vehicle accident with face-on collision at 70 mph. She was on the passenger side and had hit the dashboard because of non-functioning air bags causing sternal fracture and left lung collapse and was then discharged home after a short hospitalization. She had been asymptomatic till the current presentation.
      Fig. 1
      Fig. 1Panel a is a chest X-ray revealing a dilated stomach protruding into the left chest that was not evident 3 months earlier (panel b). Panels c and d is a chest CT-scan showing a left diaphragmatic hernia.
      What is the diagnosis?

      2. Diagnosis

      Chest pain in the presented case was caused by delayed traumatic diaphragmatic herniation from chest trauma two months earlier. The patient underwent left thoracotomy and repair of the diaphragmatic hernia. There was a 5 × 5 cm defect in the left hemidiaphragm through which the stomach herniated and was found markedly dilated, compressed at the hernial site and partially volulized. Diaphragmatic rupture mostly occurs following major trauma. Delayed presentation is either due to delayed detection or delayed rupture [
      • Johnson C.D.
      Blunt injuries of the diaphragm.
      ], the former being more likely and may present months-to-years later. Detection may be delayed if diaphragmatic tear remains asymptomatic at the time of injury and manifests only when herniation occurs. The diagnosis may be initially overlooked when other more serious injuries are attended to. In addition, there is lack of specific clinical signs, and results of initial radiologic studies may be non-specific. Delayed rupture occurs if diaphragmatic tissue is devitalized at the time of injury but maintains a fragile barrier till superimposed inflammation weakens it [
      • Dwari A.K.
      • Mandal A.
      • Das S.K.
      • Sarkar S.
      Delayed presentation of traumatic diaphragmatic rupture with herniation of the left kidney and bowel loops.
      ]. Diaphragmatic rupture results in herniation of abdominal contents to the chest because of the normal intra-abdominal to intrathoracic pressure gradient of 2–10 mmHg, which reaches up to 10 mmHg during Valsalva maneuver [
      • Brasel K.J.
      • Borgstrom D.C.
      • Meyer P.
      • Weigelt J.A.
      Predictors of outcome in blunt diaphragm rupture.
      ]. Because chest and abdominal pain are the most common reasons for emergency department admission, awareness of this presentation is crucial for emergency physicians and admitting hospitalists.

      Conflicts of interest

      There are no conflicts of interest to disclose.

      Acknowledgements

      We have received no funding for this report. All authors have read and approved the final submitted manuscript.

      References

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        Delayed presentation of traumatic diaphragmatic rupture with herniation of the left kidney and bowel loops.
        Case Rep Pulmonol. 2013; 2013: 814632
        • Brasel K.J.
        • Borgstrom D.C.
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        Predictors of outcome in blunt diaphragm rupture.
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