May 2008 - Abdominal pain 6 months after fall

Case history:

6 months prior to presentation a 52 year old bricklayer had fallen from a ladder. Chest X-ray at that time demonstrated undisplaced rib fractures with no pneumothorax and follow-up was not thought necessary. He came to hospital on this occasion with a one month history of dull upper abdominal pain.

Repeat chest X-ray showed unilateral radiolucent hemithorax on the left with a few broken ribs on that side and mediastinal shift to the right; a scaphoid abdomen was noted on examination. After review of the film, needle thoracocentesis was deferred and a CT scan performed. This showed a diaphragmatic hernia containing transverse colon. He underwent thoraco-abdominal repair of diaphramatic hernia.

The injury is uncommon, occurring in about 4% of victims of major closed chest or abdominal trauma. Large pressure differentials between the chest and abdomen, generated at the time of injury, cause tearing of the dome of the diaphragm, more commonly on the left as the liver protects the right side by spreading the forces more evenly. The injury is indicative of severe trauma and injuries that accompany such trauma often take priority at presentation, resulting in injury to the diaphragm being overlooked. In some series this has been overlooked in up to roughly two thirds of patients.

The patient may present months or years later in one of two ways.

• The first way is with mild symptoms typically in the lower chest, or epigastric pain occurring intermittently and often brought on by taking food; physical signs are minimal. This is the so called "latent"stage.
• The clinical picture may change dramatically and the patient present in the so called "late" stage with severe symptoms of pain, breathlessness, and intestinal obstruction or gastrointestinal haemorrhage.Examination may show that the patient is in shock. Theremay also be evidence of mediastinal shift, and bowel sounds may be audible in the chest. Nearly all such patients will have presented previously with minor "latent" symptoms.
  

Treatment at any stage of the illness requires an operation. Reduction of herniated contents and closure of the defect is undertaken at the time of diagnosis through a laparotomy incision in the case of an acute onset and by an appropriate thoracotomy in chronic cases. Surgery performed during the "latent" stage carries a perioperative mortality of under 10%. When surgery is undertaken in the presence of strangulation, in the "late" stage, there is a mortality of between 20% and 80%.

Conclusion:
As most patients will present with minor symptoms before presenting with a severe illness the diagnosis must always be borne in mind. In all cases an accurate history (particularly trauma), clinical alertness, and a chest radiograph are the key to diagnosis.

April 2008 - Abdominal distension and vomiting

This patient presented with vague right upper quadrant pain over a 2 month period followed by the development over 24 hours of abdominal distension and vomiting. The image shows small bowel obstruction but if you look closely in the right upper quadrant there is linear gas visible within the biliary tree and in the pelvis is a rounded opacity. This patient has gallstone ileus.

March 2008 - Sudden deterioration after thoracic surgery

This patient deteriorated acutely approximately 5 hours after return from the OR. The image demonstrates a very significant left pneumothorax despite the presence of a left chest tube which appears to be in satisfactory position. Note the "deep sulcus sign" on the left indicating air extending down anteriorly within the chest cavity and obscuring the left hemidiaphragm, and the subcutaneous emphysema along the left chest wall. In this case the chest tube became occluded by blood in a patient with a small residual air leak.