Tension fecal pneumothorax in a postpartum patient

An 88-Year-Old Woman With Pneumothorax and Black Pleural Effusion

CASE PRESENTATION

An 88-year-old woman was admitted to our hospital with the sudden onset of dyspnea after eating. The patient had undergone nephrectomy for a left renal tumor 24 years previously. The patient had been prescribed ferrous citrate for iron-deficiency anemia. She complained of appetite loss a few days before admission but had no abdominal pain. CT scan showed no abnormalities in the lungs but a mass in the liver.

Maternal Strangulated Diaphragmatic Hernia with Gangrene of the Entire Stomach During Pregnancy: A Case Report and Review of the Recent Literature

Background

Bochdalek hernia (BH) of congenital diaphragm hernia is infrequently seen in adults. Strangulation of the diaphragm hernia has been recognized as a severe complication. Among several factors, pregnancy is an important cause of diaphragm hernia's deterioration. However, nausea, vomiting, and upper abdominal pain are often considered non-specific pregnancy-related symptoms.

Case Presentation

We report a case of a 39-year-old (gravida II, para I) multigravida woman with a delayed diagnosis of strangulated herniated viscera complicating total gastric gangrene at 26+1 weeks' gestation. The preoperative diagnosis was confirmed by an X-ray examination and magnetic resonance imaging (MRI). After identifying the size and severity of the herniated contents through video-assisted thoracoscopy (VAT), we immediately converted to abdominal laparotomy. Antenatal corticosteroids were administered simultaneously with diagnosis to promote fetal maturity. The fetal condition was maintained well in the maternal uterus during the operation. Careful monitoring of the fetus and the mother's clinical conditions should be performed during expectant management to achieve delayed delivery after maternal surgical correction. Delivery was completed through cesarean delivery at 27+1 weeks of gestation.

Conclusion

Despite the rarity of maternal Bochdalek hernias during pregnancy, early diagnosis and appropriate treatment via multidisciplinary care are essential for maternal and fetal outcomes.

Undiagnosed maternal diaphragmatic hernia - a management dilemma

Background

Maternal diaphragmatic hernias identified during pregnancy are rare and pose significant management challenges with regards to timing and mode of both delivery and hernia repair.

Case presentation

We describe a case of a maternal diaphragmatic hernia diagnosed at 31 weeks gestation in the setting of acute upper abdominal pain. Due to no evidence of visceral compromise and a stable maternal condition, the patient was conservatively managed, allowing for further foetal maturation. Delivery by caesarean section occurred following concerns of malnutrition and partial bowel obstruction. This was followed by immediate surgical repair of the hernia. The patient had an uncomplicated recovery.

Conclusion

Maternal diaphragmatic hernias in pregnancy require multidisciplinary care and individualised management in order to allow for the optimal outcome for mother and foetus.

A case of tension faecopneumothorax after delayed diagnosis of traumatic diaphragmatic hernia

Background

Traumatic diaphragmatic injuries from blunt or penetrating trauma are difficult to detect in the acute setting and, if missed, can result in significant morbidity and mortality in the future. We present a case demonstrating the natural progression of this resulting in faecopneumothorax, which is a rare but serious presentation.

Case presentation

A 22-year-old young man presented with left upper quadrant and chest pain, nausea, vomiting, and intermittent obstipation with a background of previous lower chest wall stabbings. Computed tomography demonstrated a diaphragmatic hernia containing the splenic flexure of the colon, but he declined treatment and self-discharged. He presented three more times with similar symptoms and self-discharged within a 2-week period and finally presented dyspnoeic and septic. Computed tomography demonstrated tension faecopneumothorax from the perforated colon. He was taken to theatres and found to have a 3-mm perforation at his splenic flexure and underwent a segmental resection of the affected colon, intrathoracic washout, and biological mesh repair of his diaphragmatic hernia. He remained alive and postoperative recovery was uneventful.

Conclusions

A review of the literature demonstrates the rarity of traumatic diaphragmatic injuries resulting in faecopneumothorax with only a few case reports in the last 50 years. We present a case demonstrating a natural progression of the condition and highlight the importance of having a high index of suspicion of diaphragmatic injuries in the trauma setting.

Delayed traumatic diaphragmatic hernia mimicking hydropneumothorax

Traumatic diaphragmatic hernia (TDH) is generally a consequence of thoraco-abdominal trauma. Anaesthetic problems arise due to herniation of abdominal contents into the thoracic cavity causing diaphragmatic dysfunction, lung collapse, mediastinal shift and haemodynamic instability. Diagnosis depends on history, clinical signs and radiological investigations. Sometimes, it may be misdiagnosed as hydropneumothorax due to the presence of air and fluid in the viscera lying in the pleural cavity. We report a case of TDH mimicking hydropneumothorax on radiological investigations and subsequent surgical management, which led to serious complications.

Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax

A traumatic diaphragmatic hernia is a well-known complication following blunt abdominal or penetrating thoracic trauma. Although the majority of cases are diagnosed immediately, some patients may present later with a diaphragmatic hernia. It occurs in approximately 3% of abdominal traumas. Diagnosis requires a high index of suspicion since diaphragmatic injury can only reliably be ruled out by direct visualization, i.e., laparoscopy. Hence, delayed presentation with complications secondary to the injury is not uncommon. We discuss a case of a young man who presented in respiratory distress 5 years after a stab wound to the left chest. The patient was hypoxic, with a chest X-ray (CXR) demonstrating a pneumothorax with effusion. A chest tube was placed with a rush of air and feculent drainage. CT scan revealed an incarcerated transverse colon in a diaphragmatic hernia. The laparotomy demonstrated necrotic colon in the chest with gross fecal contamination in the chest. The diaphragmatic defect was closed and a Hartmann's procedure performed. The patient developed empyema in the postoperative period. Our patient is the twelfth reported case of a tension fecopneumothorax resulting from traumatic diaphragmatic herniation. This paper reviews all cases, including the diagnostic workup, operative approach, and expected postoperative course of this unusual condition.

Abdominal hernias in pregnancy

A hernia is an area of weakness or complete disruption of the fibromuscular tissues of the body wall. In addition to the body wall, hernias can occur in the diaphragm, pelvic wall, perineum, pelvic floor, and internal abdominal viscera (hernias through omental or mesenteric defects, ligaments and folds). Surgical repair of different types of hernia is the most common general surgical procedure with more than 20 million hernioplasties performed each year. Abdominal wall hernias are not common during pregnancy. Hernias can be symptomless or have minimal symptoms, including slight discomfort or pain. Such hernias are not life-threatening and should be controlled on regular basis. After spontaneous delivery and uterine involution, they should be repaired on an elective basis. It is of utmost importance for a clinician to diagnose emergent situations, which include incarceration, strangulation and perforation caused by hernia because consultation with a surgeon and emergency operation are mandatory. There is still no consensus for irreducible hernia during pregnancy, but complications during pregnancy outweigh elective operation. Therefore, hernioplasty is recommended during pregnancy, especially in early gestation.

Colopleural fistula: case report and review of the literature

We report a 28-year-old woman, pregnant, at 24 weeks, with 3-day history of right-sided chest pain and shortness of breath. Few hours after admission, she delivered a dead baby. She had a history of right partial hepatic lobotomy and cholecystectomy at UK on May 2004 because of multiple pyogenic liver abscesses. Chest examination revealed signs of hydrothorax on the right side. Chest X-ray showed pleural effusion on the right side. Pleural fluid was exudative with high neutrophils. Gram stain and culture showed multiple organisms. CT scan chest and abdomen with contrast, combined with barium enema, revealed right colothorax communication. Colothorax fistula was closed surgically. On the following days, the patient's symptoms resolved, and she was consequently discharged.

Bochdaleck’s hernia complicating pregnancy: Case report

Diaphragmatic hernia complicating pregnancy is rare and results in a high mortality rate, particularly if early surgical intervention is not undertaken. We report a case in which a woman presenting at 23 wk’s gestation was admitted with symptoms of respiratory failure and bowel obstruction due to incarceration of viscera through a left posterolateral defect of the diaphragm (Bochdalek’s hernia). Surgery (left thoracoabdominal incision) demonstrated compression atelectasis, mediastinal shift, strangulation and gangrene of the herniated viscera which led to segmental resection of the involved portion of large intestine with re-establishment of bowel continuity by end to end anastomosis. The greater omentum was partly necrotic necessitating resection. The diaphragmatic defect was closed with interrupted sutures. Postoperative period was uncomplicated. Pregnancy was allowed to continue until 39 wk’s gestation at which time elective cesarean delivery was performed. It is concluded that symptomatic maternal diaphragmatic hernia during pregnancy is a surgical emergency and requires a high index of suspicion.

Tension fecopneumothorax due to colonic perforation in a diaphragmatic hernia

A traumatic diaphragmatic hernia is a well-known complication following blunt abdominal or penetrating thoracic trauma. Although the majority of cases are diagnosed immediately, some patients may present later with a diaphragmatic hernia. A tension fecopneumothorax, however, is a rarity. We report on a patient who, 2 years after being treated for a stab wound to the chest, presented with an acute tension fecopneumothorax caused by the incarceration of the large bowel in the thoracic cavity after an intrathoracic perforation. The etiology and management of this condition are discussed.

Obstructive shock due to labor-related diaphragmatic hernia

OBJECTIVE

To report diaphragmatic hernia as a cause of obstructive shock in the peripartum period.

DESIGN

Case report.

SETTING

An adult, 12-bed medical/surgical intensive care unit of a general hospital.

PATIENTS

One patient who developed an obstructive shock following vaginal labor and was transferred under mechanical ventilation from a local hospital.

INTERVENTIONS

Central venous pressure, blood pressure, blood gas analysis, electrocardiogram, and chest radiograph during and after obstructive shock.

MEASUREMENTS AND MAIN RESULTS

During shock, systolic blood pressure was 60 mm Hg, central venous pressure was +12 mm Hg, and the electrocardiogram showed a supraventricular tachycardia and an acute cor pulmonale pattern. Chest radiograph showed signs of left diaphragmatic hernia and right mediastinal shift. Chest ultrasound examination demonstrated loops of bowel in the left pleural space. After surgical resolution of the left diaphragmatic hernia, the patient's blood pressure increased to 120/80 mm Hg, the central venous pressure decreased to +1 mm Hg, and the PaO2 increased to 154 torr (20.5 kPa) while receiving mechanical ventilation with an FiO2 of 50%. The electrocardiogram showed disappearance of the acute cor pulmonale pattern. The chest radiograph showed a central venous catheter located in a persistent left superior vena cava without abnormalities of the diaphragm, the mediastinum, or the lung.

CONCLUSION

Diaphragmatic hernia must be included in the differential diagnosis of obstructive shock in pregnant patients.

Management of spontaneous pneumothorax during pregnancy: case report and review of the literature

Spontaneous pneumothorax rarely occurs during pregnancy. Only 22 nonmalignancy-related cases have been previously published. Herein we report a case of recurrent spontaneous pneumothorax during the third trimester of pregnancy that necessitated surgical intervention. At thoracotomy, a large bulla was excised from the lower lobe of the right lung; abrasive pleurodesis was subsequently done. Postoperatively, the patient had regular contractions, which were successfully stopped with intravenous administration of magnesium sulfate. Indications, procedures, and pre-cautions for operative intervention during pregnancy are discussed.