Blunt Trauma Associated With Bilateral Diaphragmatic Rupture: A Case Report

Background: A bilateral diaphragmatic rupture is a rare event that occurs in cases of blunt thoracic-abdominal trauma.Case Presentation: We report the case of a 56-year-old female patient with pelvic fracture and second-stage bilateral rupture of the diaphragm due to a car accident. After a chest and abdominal contrast-enhanced computed tomography (CT) scan, the patient underwent emergency suturing of the left hemidiaphragm. On postoperative day (POD) 4, a CT scan performed due to the sudden onset of dyspnea revealed rupture of the right hemidiaphragm, which was not detected on the preoperative CT scan. On POD 9, the right hemidiaphragm was repaired with mesh during a right thoracotomy. The patient recovered 14 days after surgery. However, the postoperative course was complicated by an asymptomatic COVID-19 infection that significantly delayed her discharge from the hospital.Conclusions: Difficulties in preoperative diagnosis and treatment, together with the lack of data in the literature, make this type of trauma a challenge for all acute care and general surgeons.

Abnormal shadow on chest radiograph: a supra – or infradiaphragmatic finding?

Incidental findings on chest X-ray of oncological patients need further evaluation in contrast-enhanced computed tomography (CT). We report two cases of abnormal shadows, detected on radiograph, in patients with breast cancer: the first one projected under the left hemidiaphragm and the second one obscuring the right hemidiaphragm. Both patients were asymptomatic, subjected to a surgery and to a CT. The first scan revealed a 15 mm diameter nodule in left lung with smooth margins and central calcifications. Whereas, the second exam showed a subcapsular, ring, calcified lesion in the liver. In both cases, CT was essential for staging and therapeutic choice.

Chronic gastric volvulus secondary to eventration of the left hemidiaphragm due to radiation-induced phrenic nerve palsy: a rare presentation

Partial mesentericoaxial gastric volvulus associated with acquired eventration of the left dome of the diaphragm is very rare. We present the case of a 65-year-old man who presented with features of gastric outlet obstruction. He had a prior history of laryngeal cancer for which total laryngectomy was done, and adjuvant radiotherapy was administered. He was subsequently diagnosed with eventration of the left dome of the diaphragm and partial gastric volvulus. The patient recovered completely with conservative management and was discharged.

Surgery of Eventration of the Diaphragm

Background: Eventration of diaphragm is an abnormal elevation of the diaphragm. Publishing on eventration of diaphragm in Iraq is scarce. Objective: This study was carried out to report on the Iraqi experience on eventration of diaphragm. Methods: A total of 18 patients with eventration diaphragm were included in this study. A review of case records of patients with eventration diaphragm treated in Ibn Al-Nafees Teaching Hospital was done. Review of records took place for the period of March 2012 to Dec. 2017. Results: The age of patients was ranged 5 months to 70 years, giving male to female ratio of 2:1. Dyspnea was dominating presenting symptoms followed by cough. The left hemidiaphragm was the most affected site (83.3%). The cause of eventration of diaphragm was idiopathic in 72.2% of patients. Chest X ray showed the elevation of the affected hemidiaphragm. CT scan demonstrated the thinned-out raised hemidiaphragm. The most common complications were atelectasis, and recurrent chest infection. Hospital stay was ranging 4-14 days. Conclusion: Eventration of diaphragm is not uncommon in Iraq. Presentation, management, and complication are similar to that reported in global centers. Key words: Diaphragm. Eventration. Plication. Surgical repair. Phrenic nerve injury

Torsion of the wandering spleen as an abdominal emergency: a case report

Background Wandering spleen is a rare clinical entity with a less than 0.2% reporting incidence rate. In this case, the spleen is present abnormally in the abdominal or pelvic cavity instead of its normal anatomical location. The aetiology is either congenital or acquired. The condition is caused by the absence or maldevelopment of the spleen's suspensory ligaments, which holds the spleen static in the left hypochondrium. Case presentation A 27-year-old female patient presented to the emergency department with complaints of abdominal pain, fever, nausea, vomiting, and constipation for three days. A palpable movable mass was found during the physical examination, and torsion of the wandering spleen’s pedicle was confirmed by CT scan. Open splenectomy was performed, and the patient was recovered uneventfully. Conclusion Even though ectopic spleen is a rare disease, clinicians should be aware of its incidence. Early diagnosis in the case of an acute abdomen is vital for the preservation of the spleen. Patients presented with acute abdomen and absence of splenic shadow under left hemidiaphragm should be suspected, and further radiological investigation will confirm the diagnosis. Surgery is the gold standard for wandering spleen with either splenopexy or splenectomy, depending on the spleen's condition during surgery.

Normal Diaphragm Measurements in the Saudi Population Using Posteroanterior Chest Radiograph

The aim of this study was to establish normal measurements of the hemidiaphragm widths and heights in the Saudi population by a posteroanterior (PA) chest X-ray in the Mecca Region. Methods and Results: The data were collected prospectively at King Abdulaziz Hospital in Saudi Arabia, Jeddah, between March and April 2021, using a computed radiography imaging unit. A total of 45 patients (51.1% men and 48.9% women; the age range between 15 and 79 years) were included in the study. Measurements were obtained on an ideal PA chest radiograph by measuring the distance from the highest points of the right hemidiaphragm and left hemidiaphragm. The width from the right and left costophrenic angle was also measured as an ended point. The total diaphragm width (DW) was 278.32±24.83mm, the total right diaphragmatic dome height (RDDH) -51.30±10.58mm, and left diaphragmatic dome height (LDDH) - 38.40±9.21mm. The DW was greater in men than in women: 291.74±20.4mm and 264.28±21.2mm, respectively. RDDH and LDDH were also greater in men than in women: 55.4±6.77mm and 47.005±12.19mm, and 43.29±6.65mm and 33.28±8.83, respectively Conclusion: Computed radiography was useful in measuring the diaphragm because measurement points can be identified accurately and easily due to the availability of the processing system functions such as the ability to manipulate the image resolution, image contrast, and magnification.

“NOT AT HOME” !!!

A Bochdalek hernia is a posterior congenital defect of the diaphragm, usually on the left hemidiaphragm, caused by a lack of closure of the pleuroperitoneal canal between the eighth and tenth week of foetal life during the embryonic development. It typically presents in the neonatal period with severe respiratory failure. Incidental diagnosis in an asymptomatic patient presenting in adult life is rare. We report a case of an asymptomatic eighteen year old male who was incidentally discovered to have congenital diaphragmatic hernia when he was operated for testicular torsion on an emergency basis.

A RARE CASE OF ACUTE MESENTEROAXIAL GASTRIC VOLVULUS WITH SPLENIC INFARCT

Gastric volvulus is an uncommon clinical entity seen in both adults and pediatric patients. It occurs when the stomach is rotated atleast 180 degrees along its longitudinal or transverse axes. Gastric volvulus may present acutely or may present with intermittent, recurrent and chronic symptoms. In acute presentation, there is risk of strangulation of stomach leading to necrosis , perforation and shock. Hence, prompt diagnosis and treatment of acute gastric volvulus helps to decrease morbidity and mortality. We encountered a case of a 20 year old male patient who presented to the emergency department with acute onset of abdominal pain and distension. Following Contrast Enhanced Computed Tomography and upper GI endoscopy a diagnosis of acute strangulated gastric volvulus with eventeration of left hemidiaphragm was made and patient was posted for emergency laparotomy. Intraoperative ndings included mesenteroaxial volvulus of the stomach with transmural necrosis of the fundus and proximal part of body of stomach along the greater curvature with eventeration of left hemidiaphragm and superior displacement of spleen with infarct of lower part of spleen

Permanent Pacemaker Implantation Challenged by an Elevated Left Hemidiaphragm

This is a case of a 93 year old patient who presented with a syncopal episode due to infra-nodal atrio-ventricular block (AVB) which required placement of a permanent pacemaker (PPM). The initial pre-procedure chest x-ray (CXR) showed an elevated left hemidiaphragm with shifting of the heart to the right making PPM implant challenging.