Diaphragmatic Rupture with Pericardial Involvement

Transcription

1 Diaphragmatic Rupture with Pericardial Involvement Report of Two Cases Raymond M. Wetrich, M.D., Thomas M. Sawyers, M.D., and Chester A. Haug, M.D. D iaphragmatic rupture with pericardial involvement is a particularly unusual type of traumatic hernia of the diaphragm. Only eight cases can be found in the literature. We are adding two more cases which were seen at the Kaiser Foundation Hospital, Fontana, California. Our second case was diagnosed preoperatively. In only one other reported case has a preoperative diagnosis been made. Traumatic rupture of the diaphragm per se has been known for centuries. Sinnertus [9] is credited with the first description of this condition. In 1541 he described the autopsy findings in the case of a man who had been stabbed seven months previously. Ambrose Park [71 in 1579 also described the autopsy findings in two cases of traumatic diaphragmatic hernia. In 1853 Bowditch [2] reported the first antemortem diagnosis of traumatic diaphragmatic hernia in the United States. He set up five criteria for this diagnosis: (1) prominence and immobility of the left thorax; (2) displacement to the right of the area of cardiac dullness; (3) absent breath sounds on the left side; (4) presence of bowel sounds in the chest; and (5) tympany to percussion over the left chest. Another important factor that helps in the diagnosis is a high index of suspicion when dealing with patients who have sustained trauma to the chest and abdomen. CASE 1 A 52-year-old white man was admitted to the Kaiser Foundation HospitaI on December 18, 1961, after having been injured in an automobile accident. He was in moderately severe respiratory distress owing to fractured ribs on the left. His heart showed a sinus rhythm; rate was 120; and there was a grade 3 aortic systolic murmur. There were normal breath sounds anteriorly and in the axilla. There was also a comminuted fracture of the left femur. His left femur was placed From the Southern California Permanente Medical Group and the Kaiser Foundation Hospital, Fontana, Calif. Read at the Thirteenth Annual Surgical Symposium, Kaiser Foundation Hospital and Southern California Permanente Medical Group, Century City, Calif., March 1-2, Address reprint requests to Dr. Wetrich, 9961 Sierra Ave., Fontana, Calif VOL. 8, NO. 4, OCTOBER,

2 WETRICH, SAWYERS, AND HAUG in traction and he was given fluids intravenously and analgesics. Repeated portable roentgenograms of the chest showed what appeared to be an enlarged heart and a pleural reaction at the left base. The patient continued to have left chest pain, tachycardia, and rapid, shallow respirations. On the sixth hospital day, a splashing noise could be heard over the precordium, and on the seventh hospital day a pleuritic rub was heard on the left side. Because of these findings, barium contrast roentgenograms were made (Fig. 1). These showed the presence of a diaphragmatic hernia. The gas shadow superimposed on the lower portion of the cardiac silhouette was noted by the radiologist. A lateral view revealed the hernia to be anterior to the heart within the mediastinum (Fig. 2). On the twelfth hospital day, a left thoracotomy was performed. Upon opening the chest, no hernia was detected. The left diaphragm was completely intact. An incision was then made in the diaphragm. Exploration of the undersurface of the diaphragm revealed a tear into the pericardial sac. This tear was 10 cm. long and extended from a point anterior to the vertebral body along the lateral border of the pericardium (Fig. 3). The stomach was rotated upon itself and was attached to the heart by dense adhesions. These adhesions were divided, the herniated stomach reduced, and the rent in the diaphragm closed with interrupted silk sutures. The counterincision was also closed with interrupted silk. The patient s postoperative course was uneventful. 1 2 FIG. 1. The herniated barium-filled stomach is seen lying above the diaphragm. Note that the barium-filled colon is in its normal location. FIG. 2. Lateral transthoracic view demonstrates a pocket of air lying retrosternally above the diaphragm. 362 THE ANNALS OF THORACIC SURGERY

3 CASE REPORT: Diaphragmatic Rupture FIG. 3. Site of rupture of the diaphragm into the pericardial sac. CASE 2 An 18-year-old man was admitted to the Kaiser Foundation Hospital on April 29, 1964, after being extricated with difficulty from the wreckage of an automobile accident. His blood pressure was There were contusions over the left chest wall anteriorly. Both lungs were clear to auscultation. There was 4 5 FIG. 4. Part of the stomach, which has been distended with gas, lying in the pericardial sac. FIG. 5. Lateral roentgenogram of the chest showing gcls-filled stomach lying partially above the diaphragm. VOL. 8, NO. 4, OCTOBER,

4 WETRICH, SAWYERS, AND HAUG a compound, comminuted fracture of the left femur and a Monteggia fracture of the left forearm. Soon after admission the left femur was debrided and reduced, and skeletal traction was instituted. An open reduction with internal fixation of the left ulna and a closed reduction of the radial head were performed. Postoperatively, the patient complained of severe abdominal pain and nausea. There was abdominal tenderness, but operation did not appear to be indicated. Chest roentgenograms on the second hospital day revealed that the position of the left dome of the diaphragm was difficult to trace. Gas in the fundus of the stomach appeared to reach into the retrocardiac space along the left-heart border. Because of these findings, additional roentgenograms were made on the third hospital day. The radiologist reported: Following the administration of a carbonated beverage to distend the stomach with gas, the AP views of the chest and upper abdomen were obtained as well as a lateral view. It appears that a herniation of part of the fundic portion of the stomach is clearly demonstrated through a rent in the diaphragm that measures 4 cm. across (Fig. 4). The lateral view indicates that the position is far anterior in the region of the anterior mediastinum. This raises the question of a herniation into the pericardial sac. A barium,swallow on the same day reinforced this opinion. Figure 5 is a lateral view showing that the air-fluid level within the stomach is continuous beyond the level of the dome of the diaphragm into the region of the pericardium anteriorly, On the sixth hospital day, the abdomen was explored. In the left upper quadrant, 500 cc. of clotted blood was found. It was evident that there had been a rupture of the spleen and that bleeding had stopped spontaneously. There was a 5-inch laceration of the diaphragm beneath the pericardial sac. The rent was seen to extend from the right crus of the diaphragm anteriorly and laterally along the left border of the pericardium; inspection revealed that the pericardium and pleura were intact. The space between these two surfaces was occupied by the herniated stomach, neither cavity having been entered. The stomach was reduced and the rent easily repaired with 2-0 silk. A splenectomy was then performed. The patient s postoperative course was satisfactory. DISCUSSION In reviewing the literature, we have found eight other cases of traumatic rupture of the diaphragm into the pericardial sac. The first case was reported in 1952 by Crawshaw [4]. In all cases except one, the rupture followed blunt trauma [l, 3, 6, 8, 10, 111. Beddingfield [l] recently reported a case in which rupture followed a stab wound. This was associated with cardiac tamponade which had been produced by a number of loops of small intestine that had herniated into the pericardial sac. In those cases associated with blunt trauma, the interval between the accident and repair of the hernia varied from 334 months to 23 years, the average being 7 years. The symptoms have been either cardiorespiratory or gastrointestinal. In five cases, the symptoms were principally cardiac: anginal-type pain, exertional dyspnea, palpitation, tachycardia, or cardiac tamponade. Two patients were digitalized without improvement. In one interesting case reported in 1953 by Stein, Colmore, and Green [ll], a 45-year-old physician had been injured in a jeep accident in the North African campaign in He apparently recovered from his injuries and was asymptomatic until 1946, when he began to ex- $4 THE ANNALS OF THORACIC SURGERY

5 CASE REPORT: Diaphragmatic Rupture perience tachycardia, fatigue, and slight dyspnea following moderate exertion. Roentgenograms showed cardiac enlargement. He also developed what was thought to be angina. Electrocardiograms were normal. Digitalization was without effect. He actually became a cardiac cripple, and upon the advice of a cardiologist, gave up his practice. Eventually, a lateral roentgenogram of the chest suggested bowel lying above the diaphragm. A barium enema proved this to be transverse colon. An exploratory thoracotomy was performed. He was found to have a pericardial diaphragmatic hernia with a large segment of transverse colon lying inside the pericardial sac. Postoperatively, all his symptoms disappeared and he went back to his medical practice. Herman and Goldstein [5] reported in 1965 a case unique in several respects. The diagnosis was made preoperatively. Confirmation of the diagnosis was made by pneumoperitoneum. This case was also the first in which the hernia was repaired transabdominally and the repair was done 3% months after the injury. The correct diagnosis is easily missed preoperatively and has even been missed when the chest has been opened. Robb [8] reported a case in which a man had been injured in a fall 23 years previously. The intrapericardial nature of his hernia was not discovered during a left thoracotomy, and the diagnosis was finally made during a right thoraco tomy. SUMMARY Diaphragmatic rupture with pericardial involvement is a rare disease. Eight cases have been reported previously. Two additional cases are reported in this paper, including one diagnosed preoperatively. The symptoms may be either cardiorespiratory or gastrointestinal, but in particular they may mimic a severe heart disease of obscure cause. Pneumoperitoneum and upper gastrointestinal series are diagnostic. This type of hernia may be repaired transthoracically or transabdominally, but the transabdominal route seems to be the preferred method for recent injuries. REFERENCES 1. Beddingfield, G. W. Cardiac tamponade due to traumatic hernia of the diaphragm and pericardium. Ann. Thorac. Surg. 6:178, Bowditch, H. I. Diaphragmatic hernia. Buflalo Med. J. 9:65, Brookes, U. S. Intrapericardial diaphragmatic hernia. Brit. J. Surg. 40:511, Crawshaw, G. R. Herniation of the stomach, transverse colon, and a portion of the jejunum into the pericardium. Brit. J. Surg. 39:364, Herman, P. G., and Goldstein, J. E. Traumatic intrapericardial diaphragmatic hernia. Brit. J. Radiol. 38:631, VOL. 8, NO. 4, OCTOBER,

6 WETRICH, SAWYERS, AND HAUG 6. Moore, T. C. Traumatic pericardial diaphragmatic hernia. A.M.A. Arch. Surg. 79:139, Park, A. Quoted by G. E. Lindskog. Some historic aspects of thoracic trauma. J. Thorac. Cardiovasc. Surg. 42:1, 1961, 8. Robb, D. Traumatic diaphragmatic hernia into the pericardium. Brit. J. Surg. 50:664, Sinnertus. Cited by C. F. Schneider in Traumatic Hernia of the Diaphragm. In L. M. Nyhus and H. N. Harkins (Eds.), Hernia. Philadelphia: Lippincott, P Smith, L., and Lippert, K. M. Peritoneo-pericardial diaphragmatic hernia. Ann. Surg. 148:798, Stein, J., Colmore, H. D., and Green, R. A. Diaphragmatico-pericardial tear with intrapericardial herniation of the transverse colon. Radiology 60:417, THE ANNALS OF THORACIC SURGERY