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Right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literature review.

Agrusa A, Romano G, Chianetta D, De Vita G, Frazzetta G, Di Buono G, Sorce V, Gulotta G - World J Emerg Surg (2014)

Bottom Line: Diagnostic delay results in a high rate of mortality.A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy.Diagnostic delay causes high mortality with these traumas with insidious symptoms.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, Palermo 5 90127, Italy.

ABSTRACT

Introduction: Diaphragmatic injuries are rare consequences of thoracoabdominal trauma and they often occur in association with multiorgan injuries. The diaphragm is a difficult anatomical structure to study with common imaging instruments due to its physiological movement. Thus, diaphragmatic injuries can often be misunderstood and diagnosed only during surgical procedures. Diagnostic delay results in a high rate of mortality.

Methods: We report the management of a clinical case of a 45-old man who came to our observation with a stab wound in the right upper abdomen. The type or length of the knife used as it was extracted from the victim after the fight. CT imaging demonstrated a right hemothorax without pulmonary lesions and parenchymal laceration of the liver with active bleeding. It is observed hemoperitoneum and subdiaphragmatic air in the abdomen, as a bowel perforation. A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy.

Conclusion: In countries with a low incidence of inter-personal violence, stab wound diaphragmatic injury is particularly rare, in particular involving the right hemidiaphragm. Diaphragmatic injury may be underestimated due to the presence of concomitant lesions of other organs, to a state of shock and respiratory failure, and to the difficulty of identifying diaphragmatic injuries in the absence of high sensitivity and specific diagnostic instruments. Diagnostic delay causes high mortality with these traumas with insidious symptoms. A diaphragmatic injury should be suspected in the presence of a clinical picture which includes hemothorax, hemoperitoneum, anemia and the presence of subdiaphragmatic air in the abdomen.

No MeSH data available.


Related in: MedlinePlus

Computed tomography results of the patient. a) presence of a right hemothorax without pulmonary lesions; b) discrete hemoperitoneum by an active bleeding parenchymal liver laceration and “free air” in the abdomen.
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Figure 1: Computed tomography results of the patient. a) presence of a right hemothorax without pulmonary lesions; b) discrete hemoperitoneum by an active bleeding parenchymal liver laceration and “free air” in the abdomen.

Mentions: From the scan, the presence of a right hemothorax without pulmonary lesions was seen, with moderate hemoperitoneum from an active bleeding parenchymal liver laceration and subdiaphragmatic air in the abdomen as a bowel perforation (Figure 1). Initially, the suspect of a bowel perforation suggested a laparoscopic approach, but the patient’s hemodynamic condition rapidly changed. In the operating room, the patient presented pale with tachycardia; blood pressure decreased to 90/60 mm Hg and cardiac frequency increased to 115 bpm. A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy [6,7]. After laparotomy, a significant amount of blood was evacuated to identify the site of bleeding. Liver inspection showed an 8 cm long, 1 cm deep laceration with active bleeding in segments IV-V (Grade II lesion classification AAST). A careful inspection of the abdominal cavity also showed a 12 cm length right diaphragmatic lesion with signs of active bleeding that accounted for the presence of free air seen in the CT images. No other intestinal lesions were found. Temporary packing was used to treat the liver bleeding. After evacuating the right hemothorax, we proceeded with repair of the diaphragmatic lesion with non-absorbable sutures, and by placing a thoracic Bouleau drainage. The suture was completed applying a medicated sponge containing thrombin and human fibrinogen in order to control hemostasis and facilitate the building of the tissues and healing process [8]. After stopping the bleeding from the liver and bile leakage it was decided to adopt a conservative approach applying hemostatic matrix on liver injury (Figure 2). Surgery was concluded with the placement of abdominal drains, in the right subphrenic space. One transfusion was carried out during surgery. In post-operative time, blood pressure was 120/80 mmHg, hemoglobin 9 mg/dl. Chest tube was removed 4 days post surgery, after an x-ray which confirmed resolution of hemopneumothorax.


Right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literature review.

Agrusa A, Romano G, Chianetta D, De Vita G, Frazzetta G, Di Buono G, Sorce V, Gulotta G - World J Emerg Surg (2014)

Computed tomography results of the patient. a) presence of a right hemothorax without pulmonary lesions; b) discrete hemoperitoneum by an active bleeding parenchymal liver laceration and “free air” in the abdomen.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4016783&req=5

Figure 1: Computed tomography results of the patient. a) presence of a right hemothorax without pulmonary lesions; b) discrete hemoperitoneum by an active bleeding parenchymal liver laceration and “free air” in the abdomen.
Mentions: From the scan, the presence of a right hemothorax without pulmonary lesions was seen, with moderate hemoperitoneum from an active bleeding parenchymal liver laceration and subdiaphragmatic air in the abdomen as a bowel perforation (Figure 1). Initially, the suspect of a bowel perforation suggested a laparoscopic approach, but the patient’s hemodynamic condition rapidly changed. In the operating room, the patient presented pale with tachycardia; blood pressure decreased to 90/60 mm Hg and cardiac frequency increased to 115 bpm. A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy [6,7]. After laparotomy, a significant amount of blood was evacuated to identify the site of bleeding. Liver inspection showed an 8 cm long, 1 cm deep laceration with active bleeding in segments IV-V (Grade II lesion classification AAST). A careful inspection of the abdominal cavity also showed a 12 cm length right diaphragmatic lesion with signs of active bleeding that accounted for the presence of free air seen in the CT images. No other intestinal lesions were found. Temporary packing was used to treat the liver bleeding. After evacuating the right hemothorax, we proceeded with repair of the diaphragmatic lesion with non-absorbable sutures, and by placing a thoracic Bouleau drainage. The suture was completed applying a medicated sponge containing thrombin and human fibrinogen in order to control hemostasis and facilitate the building of the tissues and healing process [8]. After stopping the bleeding from the liver and bile leakage it was decided to adopt a conservative approach applying hemostatic matrix on liver injury (Figure 2). Surgery was concluded with the placement of abdominal drains, in the right subphrenic space. One transfusion was carried out during surgery. In post-operative time, blood pressure was 120/80 mmHg, hemoglobin 9 mg/dl. Chest tube was removed 4 days post surgery, after an x-ray which confirmed resolution of hemopneumothorax.

Bottom Line: Diagnostic delay results in a high rate of mortality.A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy.Diagnostic delay causes high mortality with these traumas with insidious symptoms.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, Palermo 5 90127, Italy.

ABSTRACT

Introduction: Diaphragmatic injuries are rare consequences of thoracoabdominal trauma and they often occur in association with multiorgan injuries. The diaphragm is a difficult anatomical structure to study with common imaging instruments due to its physiological movement. Thus, diaphragmatic injuries can often be misunderstood and diagnosed only during surgical procedures. Diagnostic delay results in a high rate of mortality.

Methods: We report the management of a clinical case of a 45-old man who came to our observation with a stab wound in the right upper abdomen. The type or length of the knife used as it was extracted from the victim after the fight. CT imaging demonstrated a right hemothorax without pulmonary lesions and parenchymal laceration of the liver with active bleeding. It is observed hemoperitoneum and subdiaphragmatic air in the abdomen, as a bowel perforation. A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy.

Conclusion: In countries with a low incidence of inter-personal violence, stab wound diaphragmatic injury is particularly rare, in particular involving the right hemidiaphragm. Diaphragmatic injury may be underestimated due to the presence of concomitant lesions of other organs, to a state of shock and respiratory failure, and to the difficulty of identifying diaphragmatic injuries in the absence of high sensitivity and specific diagnostic instruments. Diagnostic delay causes high mortality with these traumas with insidious symptoms. A diaphragmatic injury should be suspected in the presence of a clinical picture which includes hemothorax, hemoperitoneum, anemia and the presence of subdiaphragmatic air in the abdomen.

No MeSH data available.


Related in: MedlinePlus