Absent lung slide but no pneumothorax: A case of spontaneous diaphragmatic hernia presenting with dyspnea

Margi Tusharbhai Bhatt; R Sunil; R Shwethapriya

doi:10.4103/ijrc.ijrc_5_20

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CASE REPORT

Year : 2020 | Volume : 9 | Issue : 2 | Page : 224-226

Absent lung slide but no pneumothorax: A case of spontaneous diaphragmatic hernia presenting with dyspnea

Margi Tusharbhai Bhatt, R Sunil, R Shwethapriya
Department of Critical Care Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission	21-Jan-2020
Date of Decision	23-Feb-2020
Date of Acceptance	04-Mar-2020
Date of Web Publication	07-Jul-2020

Correspondence Address:
Dr. Margi Tusharbhai Bhatt
A-1604, Royal Embassy Apartment, End Point Road, Manipal - 576 104, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijrc.ijrc_5_20

Abstract

Spontaneous diaphragmatic rupture is one of the rarest thoracoabdominal emergencies. The diagnosis may be delayed if a patient presents with respiratory symptoms without any history of trauma. In this report, we present a case who was admitted to the emergency department with shortness of breath, nausea, vomiting lasting for 3 h, and was diagnosed initially with pneumothorax based on chest X-ray and ultrasonography thorax findings. An intercostal drain was placed in the emergency ward. This was later diagnosed to have spontaneous diaphragmatic rupture. The patient was operated upon, and the defect was repaired. Diaphragmatic rupture should be considered along with other possible diagnoses, especially in the presence of suspicious appearances on the chest radiography in a patient with respiratory and/or gastrointestinal symptoms. The utility of bedside ultrasound in the diagnosis of spontaneous diaphragmatic hernia is yet unproven. The only treatment is surgical along with supportive care.

Keywords: Absent lung slide, dyspnea, spontaneous diaphragmatic rupture, thoracoabdominal emergency

How to cite this article:
Bhatt MT, Sunil R, Shwethapriya R. Absent lung slide but no pneumothorax: A case of spontaneous diaphragmatic hernia presenting with dyspnea. Indian J Respir Care 2020;9:224-6

How to cite this URL:
Bhatt MT, Sunil R, Shwethapriya R. Absent lung slide but no pneumothorax: A case of spontaneous diaphragmatic hernia presenting with dyspnea. Indian J Respir Care [serial online] 2020 [cited 2021 Oct 28];9:224-6. Available from: http://www.ijrc.in/text.asp?2020/9/2/224/289085

Introduction

Diaphragmatic injuries are rare to find in clinical practice. They most commonly happen as a result of penetrating or nonpenetrating chest or abdominal trauma, with a prevalence of approximately 0.8%–15%.^[1],[2] Spontaneous diaphragmatic rupture is rare when compared to traumatic rupture, and it is often overlooked. It is difficult to consider in differential diagnosis, especially when there is no history of trauma. After obtaining appropriate consent from the patient, we hereby present a case of spontaneous diaphragmatic hernia (SDH), admitted to the emergency department with symptoms of vomiting and shortness of breath of 3 hours duration. The patient was initially diagnosed to have pneumothorax but later found to have spontaneous diaphragmatic rupture.

Case Report

A 20-year-old woman working as a laborer presented with a chief complaint of shortness of breath following 2–3 bouts of vomiting and severe epigastric pain radiating to back for 3 h. She had a history of similar complaints 1 year back which was spontaneously resolved. On arrival, her pulse rate was 140/min, feeble, ygen saturation on room air was 90%, and blood pressure was 80/60 mmHg. After initial resuscitation, an urgent chest X-ray taken showed left-sided hyperlucency of the lung and mediastinal shift to the right [Figure 1]. Ultrasound thorax showed absent lung slide on the left side. The patient had a cardiac arrest, and return of spontaneous circulation was achieved after six cycles of cardiopulmonary resuscitation given as per advanced cardiovascular life support protocol. An intercostal drain (ICD) was inserted in the left fifth intercostal space suspecting tension pneumothorax. The airway was secured, and noradrenaline infusion was commenced through the right internal jugular vein.

Figure 1: Chest X‑ray on admission showing lung hyperinflation on the left side with mediastinal shift

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After stabilization, a contrast-enhanced computed tomography (CT) thorax-abdomen-pelvis was done which was suggestive of diaphragmatic rupture with a defect of 4 cm × 6.8 cm with herniation of the stomach, duodenum, and transverse colon into the thoracic cavity [Figure 2] and [Figure 3]. There was a near-total collapse of the left lung with right mediastinal shift. Urgent surgical and cardiothoracic surgery consultation was obtained, and she was shifted to the operation theater for emergency exploratory laparotomy along with mesh repair of diaphragmatic hernia and laparostomy with Bogota bag application [Figure 4]. Her blood investigations were normal without any evidence of other organ damage throughout her hospital stay. She was extubated on postoperative day 3. Gradually, she was started on Ryle's tube feed. The patient was taken up on postoperative day 5 for reapplication of Bogota bag followed by the closure of abdominal wound with vacuum-assisted closure (VAC) dressing application. Gradually, her vasopressor supports were tapered off, and she was weaned from the ventilator. She was alert and coherent. She was continued on intravenous antibiotics, enteral feeding, electrolyte supplementation, and other supportive care. The patient was shifted to the step down-intensive care unit (ICU). Chest X-ray on discharge from ICU was completely normal [Figure 5]. She was advised to continue VAC dressings at home and advised to follow-up on an outpatient department basis.

Figure 2: Computed tomography thorax and abdomen showing diaphragmatic rupture

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Figure 3: Computed tomography thorax and abdomen showing diaphragmatic rupture with intercostal drain just anterior to the stomach wall

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Figure 4: Postlaparostomy Bogota bag application

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Figure 5: Chest X-ray on discharge from the intensive care unit

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Discussion

SDH is a condition in which there is a rupture of the diaphragm in the absence of any penetrating injury. It usually occurs due to increasing intra-abdominal pressure or increased pressure on the chest wall as in case of persistent coughing, sneezing, nausea, and vomiting. It is difficult to diagnose SDH if there is no history of visceral organ injury. Even with the history of trauma, the diagnosis can be delayed because of nonspecific symptoms. In our case, the patient had presented with nonspecific respiratory and gastrointestinal complaints without any history of trauma.^[3],[4]

In the presence of a diaphragmatic defect, frequently herniating abdominal organs are the stomach, small intestine, colon, and rarely the liver and spleen. Symptoms in such cases will be organ specific. For example, in patients with stomach herniation into the thoracic cavity, nausea, and vomiting will be the presenting complaints. In our case, the diaphragmatic defect was approximately 4 cm × 6.8 cm. Intra-abdominal contents that herniated into the thoracic cavity were stomach, small intestine, and a part of the transverse colon that explained the patient's complaints of persistent vomiting. The patient was working as a laborer and had a history of lifting heavy weights.

Losanoff et al. showed in their study that spontaneous rupture of the diaphragm was 68% more common on the left side.^[5] They showed that the most common organs herniated were the stomach (43%), colon (29%), and omentum (29%). They also showed that the most common symptoms were abdominal pain, nausea, vomiting, and breathing difficulty.^[5] The various reasons for diaphragmatic ruptures were coughing (32%), exertion (21%), and even normal vaginal delivery (14%).^[5] On the chest radiography, diagnostic features of spontaneous diaphragmatic rupture are visualization of bowel haustrations, gas shadow within the intra-abdominal cavity, shifting of diaphragm above its normal anatomical position, mediastinal shift toward opposite side, pulmonary mass-like appearance, pneumothorax, and hydropneumothorax. The CT of the thorax is another imaging modality of choice in such patients. The sensitivity for the detection of SDH on CT varies between 71% and 90%.^[6],[7]

Our patient had left-sided hyperlucency of the lung and mediastinal shift to the right on chest radiograph. Ultrasound thorax was done in the emergency department which showed absent lung slide on the left side. Left ICD inserted suspecting tension pneumothorax was just anterior to the stomach wall, as seen in the CT thorax [Figure 3]. Even when chest X-ray is suggestive of hyperlucent lung field with mediastinal shift, always care should be taken while diagnosing left-sided pneumothorax. In this case, there was no deep sulcus sign. Whenever the possibility of spontaneous diaphragmatic rupture is considered, CT thorax and abdomen will help in accurate diagnosis of the same.

Spontaneous diaphragmatic rupture should be included in the differential diagnosis based on the history and physical examination. Red flag signs include the presence of known diaphragmatic defect, difficulty in breathing preceded by nausea, vomiting, or any condition that can lead to a sudden increase in intra-abdominal pressure. Imaging is required to make the diagnosis. Chest radiography is helpful in diagnosis in 25%–50% of cases. Ultrasound can be complicated by scattering of the beam by the aerated lung and gas-filled intestinal structures. Lichtenstein et al. stated that the positive predictive value of abolished lung slide for pneumothorax was as low as 56% in the critically ill, further reduced to 27% in patients with respiratory failure. CT is the most accurate imaging modality available in the emergency department.^[8],[9],[10] A surgical treatment option is decided by the side of herniation, contents herniated into the intrathoracic cavity, and duration of the presence of SDH. In our case, emergency exploratory laparotomy along with mesh repair of diaphragmatic hernia and laparostomy with Bogota bag application was done. This procedure was followed by the application of VAC dressing.

Conclusion

Spontaneous diaphragmatic rupture is one of the possibilities when there are suspicious appearances on chest radiography with respiratory and/or gastrointestinal symptoms. As the utility of bedside ultrasound in the diagnosis is yet unproven, CT chest and abdomen should be considered for confirming the diagnosis. While the treatment is surgical, supportive measures can be taken in the ICU to alleviate symptoms and suffering.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her names and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Leppäniemi A, Haapiainen R. Diagnostic laparoscopy in abdominal stab wounds: A prospective, randomized study. J Trauma 2003;55:636-45.
2.	Asensio JA, Petrone P. Diaphragmatic injury. In: Cameron JL, editors. Current Surgical Therapy. 8^th ed. Philadelphia: Elsevier Mosby Co; 2004. p. 946-55.
3.	Tyagi A, Mohta M. Right-sided spontaneous diaphragmatic hernia with hydropneumothorax: A difficult diagnosis. SAARC J Anaesth 2008;1:94-6.
4.	Divisi D, Imbriglio G, De Vico A, Crisci R. Right diaphragm spontaneous rupture: A surgical approach. ScientificWorldJournal 2011;11:1036-40.
5.	Losanoff JE, Edelman DA, Salwen WA, Basson MD. Spontaneous rupture of the diaphragm: Case report and comprehensive review of the world literature. J Thorac Cardiovasc Surg 2010;139:e127-8.
6.	Matsevych OY. Blunt diaphragmatic rupture: Four year's experience. Hernia 2008;12:73-8.
7.	Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG. Imaging of diaphragmatic injury: A diagnostic challenge? Radiographics 2002;22 Spec No: S103-16.
8.	Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care 2014;4:1.
9.	Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest 1995;108:1345-8.
10.	Lichtenstein D, Mezière G, Biderman P, Gepner A. The “lung point”: An ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26:1434-40.