Traumatic Intercostal Pulmonary Hernia - Semes

More documents

Recommendations

Info

LETTERS TO THE EDITOR bed, with air and multiple images suggestive of calcium stones. We performed puncture and aspiration of the lesion which drew out purulent fluid, so a percutaneous drain was placed. The final diagnosis was cholecystitis complicated by a subphrenic abscess. For the diagnosis of subphrenic abscess it is especially important to correlate information obtained from medical history, examination, laboratory data and the findings of imaging tests. One needs to bear in mind that the existence of septic intra-abdominal or pelvic inflammatory processes, hollow visceral perforations, abdominal trauma - primarily of the hypochondria - or abdominal surgery may favour the development of this picture. Thus subphrenic abscess should be suspected in any patient with a history such as that here described and the signs and symptoms of sepsis; physical examination shows limited respiratory movements, pain on compression of the base of the chest, upper quadrant percussion pain or elevation of the hemidiaphragm on the affected side. Treatment is aimed at controlling sepsis with antibiotics and abscess drainage either percutaneously under ultrasound or CT control, or surgery. References 1 Gervais DA, Ho CH, O’Neill MJ, Arellano RS, Hahn PF, Mueller PR. Recurrent abdominal and pelvic abscesses: incidence, results of repeated percutaneous drainage, and underlying causes in 956 drainages. Am J Roentgenol. 2004;182:463-6. 2 Cinat ME, Wilson SE, Din AM. Determinants for successful percutaneous image-guided drainage of intra-abdominal abscess. Arch Surg. 2002;137:845-9. Chiladiti sign Estela FERNÁNDEZ CUADRIELLO, Ángela MEILÁN MARTÍNEZ, Bonel ARGÜELLES GARCÍA, Susana Ana ÁLVAREZ GONZÁLEZ Servicio de Urgencias. Hospital Universitario Arnau de Vilanova. Lleida, Spain. Sir, Chilaiditi sign is a rare radiological finding that may be confused with images leading to misdiagnosis of chest and abdominal trauma. A 45 year-old man with unremarkable medical history was admitted to our centre after a motorcycle accident in which he crashed into a wall. Initial examination showed: Glasgow Coma Scale score of 15, blood pressure 140/80 mmHg, heart rate 93 bpm, respiratory rate 30 rpm, arterial SaO 2 96% and FiO 2 0.5. He presented chest pain, left dorsal erosion and hypophonesis, subcutaneous emphysema, good mechanical ventilation without cervical tracheal deviation or jugular engorgement, correct cardiac auscultation and pulses, abdomen soft and depressible, without pain or peritonitis, and stable pelvis, no evidence of spinal injury, with multiple contusion and erosion of the limbs. Plain chest X-ray showed a small pneumothorax and left pleural effusion, fractured left ribs 3, 4, 5, 6, 7, and an image of air between the liver and the diaphragm on the right (Figure 1) obtained with computed tomography (CT) scan which was diagnosed as Chilaiditi sign. Follow up CT studies showed left lung contusion and a space-occupying hepatic lesion, compatible with hemangioma. After chest drainage, epidural analgesia and ventilatory physiotherapy, he regained physiological respiration. Chilaiditi sign is found in 0.28% of standing chest X-rays 1 , predominantly in men over 65 years of age 2 . First described in 1910 by the radiologist Demetrius Chilaiditi Demetrius, it is a positional anomaly of the colon, and rarely the small intestine, characterized by the interposition of a loop of the colon between the right hemidiaphragm and the liver 3 , rarely found on the left side 4 . It is usually asymptomatic although some patients report abdominal discomfort, insidious constipation and nausea that are usually self-limiting, although the clinical relationship with the colon interposition is controversial 3 . As predisposing factors, certain authors have cited liver atrophy, abnormal colon position and elongation, paralysis of the phrenic nerve, hypothyroidism, obesity and mental disorders 4 . The emergence of volvulus 5 is a rare complication. The absence of abdominal symptoms, or free intra-abdominal fluid/gas on Eco FAST and CT scan in the ED in our case, ruled out pneumoperitoneum. Despite the scarce clinical symptoms associated with traumatic diaphragmatic hernia6 and the limited diagnostic capacity of X-ray and CT scan for this condition 7 , radiological study and the mechanism of impact with high left chest injuries, less frequent on the right (5 - 20% of traumatic diaphragmatic rupture (0.8 to 3.6%) 8 , right traumatic diaphragmatic rupture with herniation of bowel contents was considered unlikely. Other lesions such as subphrenic abscess or hydatid cyst 9 were ruled out by the absence of findings in the laboratory tests and medical history. Some authors recommend supine chest x- ray for diagnosis 10 . The use of CT scan helps to confirm the diagnosis. Caution should be taken when performing invasive techniques in the Emergencias 2010; 22: 154-160 159
LETTERS TO THE EDITOR A area, such as liver biopsy, to avoid iatrogenic lesions 10 . Jordi MELÉ OLIVÉ, Fernando HERRERÍAS GONZÁLEZ, Cristina GAS RUÍZ, Enrique SIERRA GRAÑÓN Servicio de Cirugía General y Aparato Digestivo. Hospital Universitario Arnau de Vilanova. Lleida, Spain. References B 1 Vessal K, Borhanmanesh F. Hepatodiagramatic interposition of the intestine (Chilaiditi's syndrome). Clin Radiol. 1976;27:113-6. 2 Torgensen J. Suprahepatic interposition of the colon and volvulus of the coecum. Am J Roentgenol. 1951;66:747-51. 3 Tzimas T, Baxevanos G, Akritidis N. Chilaiditi’s Sign. Lancet. 2009;373:836. 4 Kamiyoshihara M, Ibe T, Takeyoshi I. Chilaiditi’s Sign mimicking a traumatic diaphragmatic hernia. Ann Thorac Surg. 2009;87:959-61. 5 Haddad CJ, Lacle J. Chilaiditi’s syndrome: a diagnostic challenge. Postgrad Med. 1991;89:249-50. 6 Mele Olive J, Nogué Bou R. Rotura diafragmática traumática asociada a gastro-colo-espleno-tórax. Emergencias. 2005;17:96-7. 7 Rodríguez Morales G, Rodríguez A, Shatney CH. Acute rupture of the diaphragm in blunt trauma: analisis of 60 patients. J Trauma. 1986;26:438-44. 8 Kozak O, Mentes O, Harlak A, Yigit T, Kilbas Z, Aslan I, et al. Late presentation of blunt right diaphragmatic rupture (hepatic hernia). Am J Emerg Med. 2008;26:638. 9 Shridar G, Leow CK. Free air or colon? Ann Coll Surg. 2003;7:136-8. 10 Prassopoulos PK, Raissaki MT, Gourtsoyiannis NC. Hepatodiaphragmatic interposition of the colon in the upright and supine position. J Comput Assist Tomogr. 1996;20:151-3. Figure 1. Chest X-ray: A) Note the right subdiaphragmatic air and right rib fractures and left pleural effusion. B) Lateral view in which the haustral folds were identified. 160 Emergencias 2010; 22: 154-160
Page 1 and 2: CARTAS AL EDITOR LETTERS TO THE EDI
Page 3 and 4: LETTERS TO THE EDITOR Protruding at
Page 5: LETTERS TO THE EDITOR Subphrenic ab

Traumatic Intercostal Pulmonary Hernia - Semes

Create successful ePaper yourself

Delete template?

Save as template?