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July 20, 2009

Image of the Month—Diagnosis

Arch Surg. 2009;144(7):693-694. doi:10.1001/archsurg.2009.106-b

Answer: Diaphragmatic Hernia With Intestinal Obstruction

The chest radiographs showed multiple air fluid levels in the left hemithorax. The contour of the diaphragm could not be seen on the left side and intestinal loops were seen in the chest. The stomach outline could be made out in the anterior left hemithorax. These findings with a history of trauma led to a diagnosis of traumatic diaphragmatic hernia of the left side (anterior) with herniation of the stomach and small-bowel loops with intestinal obstruction. Ultrasonography was done for confirmation.

The most common cause of acquired diaphragmatic hernias is either blunt or penetrating trauma. Blunt trauma accounts for 75% of ruptures, and penetrating trauma accounts for the majority of the rest. The incidence of diaphragmatic rupture is 0.8% to 1.6% in patients admitted to the hospital for blunt trauma. Motor vehicle accidents are the leading cause of blunt diaphragmatic injury, whereas penetrating injuries result from gunshot or stab wounds. Other rare causes of traumatic rupture include labor in women with a history of congenital or repaired diaphragmatic hernias and barotrauma during underwater dives in patients with history of Nissen fundoplication. The male to female ratio is 4:1, with most presenting in the third decade of life. Left-sided rupture is more common than right-sided rupture (68.5% vs 24.2%) owing to hepatic protection and increased strength of the right hemidiaphragm. This may also result from weakness in points of diaphragmatic embryologic fusion especially along either side of the esophagus where pleuroperitoneal canals are closed by the formation of pleuroperitoneal membranes.

Delayed presentation of diaphragmatic hernia is already well established, with presentations delayed up to 28 years after trauma. Hegarty et al1have described 25 patients with traumatic diaphragmatic hernia discovered at least 5 months after injury. Alimoglu et al2reported 3 cases of delayed traumatic diaphragmatic hernias presenting with strangulation after blunt trauma in 2 patients and penetrating trauma in 1 patient. Tauro et al3described a patient with delayed traumatic obstructed diaphragmatic hernia after blunt chest trauma.

Most patients with delayed presentation of traumatic diaphragmatic hernias recover and remain symptom free after the immediate posttraumatic period. This period may vary, from months to years, the longest reported being 28 years. Patients usually present with an acute crisis and do not stress the history of trauma. Rupture of the diaphragm leads to herniation of abdominal organs into the chest. Common viscera herniated include the stomach (most common), colon, small bowel, and spleen. The symptoms may be those of classic intestinal obstruction with abdominal pain and distention, vomiting, and air fluid levels on abdominal radiographs or upper abdominal and/or chest pain with vomiting and dyspnea. The differential diagnosis includes cholecystitis, pancreatitis and perforation of a peptic ulcer, myocardial infarction, pneumonia, or even hydropneumothorax. Clinical findings confirming the diagnosis include respiratory distress, decreased breath sounds on the affected side, aspiration of abdominal contents on insertion of a chest tube, auscultation of bowel sounds in the chest, paradoxical movement of the abdomen with breathing, and/or diffuse abdominal or chest pain. The diagnosis may be missed during first evaluation (in up to 14.6% of the cases4), resulting in chronic diaphragmatic hernia and/or strangulation.

Traumatic rupture of the diaphragm requires urgent surgical intervention whether the patient presents immediately or some time after the trauma. The abdominal approach is preferred in the acute trauma setting because of the high incidence of concomitant abdominal injury.

Patients complaining of upper abdominal pain and dyspnea with a history of thoracoabdominal trauma should be evaluated for a missed diaphragmatic injury. A high index of suspicion, physical examination of the chest, and radiography are helpful for diagnosis of delayed traumatic diaphragmatic hernias presenting with strangulation.

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Correspondence:Ankit Shrivastav, MBBS, Room 235, Junior Doctors Hostel, SSKM Hospital, 242, AJC Bose Road, Kolkata 700 020, India (

Accepted for Publication:November 17, 2008.

Author Contributions:Study concept and design: Shrivastav. Acquisition of data: Shrivastav. Analysis and interpretation of data: Shrivastav and Chakraborty. Drafting of the manuscript: Shrivastav. Critical revision of the manuscript for important intellectual content: Chakraborty. Administrative, technical, and material support: Shrivastav. Study supervision: Chakraborty.

Financial Disclosure:None reported.

Hegarty  MMBryer  JVAngorn  IBBaker  LW Delayed presentation of traumatic diaphragmatic hernia.  Ann Surg 1978;188 (2) 229- 233PubMedGoogle ScholarCrossref
Alimoglu  OEryilmaz  RSahin  MOzsoy  MS Delayed traumatic diaphragmatic hernias presenting with strangulation.  Hernia 2004;8 (4) 393- 396PubMedGoogle ScholarCrossref
Tauro  LFRao  BSSHegde  BRPeter  AIGulvadi  RK Obstructed/strangulated diaphragmatic hernia: a rare cause of acute intestinal obstruction in adults.  Ind J Thorac Cardiovasc Surg 2006;22 (4) 233- 235Google ScholarCrossref
Shah  RSabanathan  SMearns  AJChoudhury  AK Traumatic rupture of diaphragm.  Ann Thorac Surg 1995;60 (5) 1444- 1449PubMedGoogle ScholarCrossref