Confusing Finding in Hepatic Injury With Diaphragmatic Rupture

Article information

Trauma Image Proced. 2019;4(1):1-2
Publication date (electronic) : 2019 May 31
doi : https://doi.org/10.24184/tip.2019.4.1.1
Department of Surgery, Yonsei university Wonju college of medicine, Wonju Severance Christian Hospital, Trauma center
Correspondence to: Pil Young Jung, Department of Surgery, Yonsei university Wonju college of medicine, Wonju Severance Christian Hospital, Trauma center, 220-701, 20 Ilsan-ro, Wonju-si, Gangwon-do, South Korea Tel: 82-33-741-0882, Fax: 82-33-741-0574, E-mail: surgery4trauma@yonsei.ac.kr
Received 2019 March 3; Revised 2019 May 8; Accepted 2019 May 8.

Abstract

Diaphragmatic injuries are relatively rare after blunt trauma. In some situations, these injuries may be hard to characterize during the initial survey and evaluation. In the case described here, diaphragmatic rupture with hepatic injury had confusing manifestations.

CASE

A 34-year-old man who had no medical history was admitted via an emergency room with blunt trauma. At admission, he was in shock status, and focused abdominal sonography for trauma showed a minimal positive sign but no abdominal distention. A trauma series showed right-sided tension hemothorax, and a chest tube was inserted (Fig. 1.). More than 1000 mL gushed out within 30 minutes. Other injuries were fractures of the pelvic bone, tibia (open), and humerus. Therefore, emergency surgery for hemothorax was planned. Before going to surgery, I wanted to check the computed tomographic (CT) scan because the vital signs were stable for permissive hyportension. However, the CT scan showed a liver injury with unexpected diaphragmatic rupture (Fig. 2A., B.). Thus the plan for thoracic surgery had to be changed to abdominal surgery. A severe liver injury with diaphragmatic rupture was found (Fig. 3.). Because of the diaphragmatic rupture, I had missed the presence of hemoperitoneum and misinterpreted the tension hemothorax as resulting from a chest injury. I performed laparotomy and midsternotomy and then attempted surgical damage control, including tape packing around the liver and temporary abdomen closure. However, the patient died 2 days after surgery.

Fig. 1.

Plain anteroposterior chest radiograph, showing right-sided tension hemothorax.

Fig. 2.

Computed tomographic scan, showing diaphragmatic rupture with liver injury.

Fig. 3.

Liver injury (grade IV) and diaphragmatic rupture in operation finding.

DISCUSSION

Diaphragmatic injuries, including ruptures, are caused by thoracoabdominal blunt or penetrating trauma. They occur in a context of multiple traumas [1]. Early diagnosis is most important, but evaluations of diaphragmatic rupture are not easy to find because diaphragmatic rupture often accompanies injuries to other organs, and intensive care, such as use of a ventilator, is necessary because vital signs are unstable [2]. The diagnosis of diaphragmatic wounds and rupture remains difficult and is often delayed [3]. In some trauma situations, proper diagnosis may be hard to establish during the initial survey and evaluation, and the manifestations may be confusing. Therefore, clinicians must use multidisciplinary approaches in treating multiple injuries.

Notes

Conflicts of Interest Statement

None of authors have a conflict of interest.

References

1. Bosanquet D, Farboud A, Luckraz H. 2009;A review diaphragmatic injury. Respir Med CME 2:1–6.
2. Hwang SW, Kim HY, Byun JH. Management of patients with traumatic rupture of the diaphragm. Korean J Thorac Cardiovasc Surg 2011;Oct. 44(5):348–54.
3. Thiam O, Konate I, Gueye ML, et al. Traumatc diaphragmatic injuries: epidemiological, diagnostic and therapeutic aspects. Springerplus 2016;Sep. 20. 5(1):1614.

Article information Continued

Fig. 1.

Plain anteroposterior chest radiograph, showing right-sided tension hemothorax.

Fig. 2.

Computed tomographic scan, showing diaphragmatic rupture with liver injury.

Fig. 3.

Liver injury (grade IV) and diaphragmatic rupture in operation finding.