Iatrogenic stomach perforation complicating unrecognized posttraumatic diaphragmatic hernia ( Gastro Thorax )

We report a case of 21-year-old male patient with traumatic diaphragmatic herniation of the stomach that is misdiagnosed as a hemo-pneumothorax with the resulting insertion of a chest tube causing iatrogenic perforation of the stomach and draining of gastric content into the pleural cavity. An emergency thoracotomy was performed, and the stomach has been repaired and reduced to the abdomen, followed by repair of the left diaphragm. Postoperative wound infection due to residual empyema was treated aggressively. We discussed and highlighted the diagnostic approach to clinical management of traumatic diaphragmatic rupture (TDR) and the importance of using nasogastric (NG) tube to avoid occurrence of such iatrogenic trauma.

raumatic diaphragmatic rupture after blunt trauma is a marker of severity 1 .Herniations of the abdominal content throw the defect in the diaphragm occur as the intra thoracic pressure is lower than that of the intra abdominal pressure 2 .Different case reports mentioned different causes for stomach perforation: • Due to severity of trauma with great impact on the herniating stomach resulting in immediate perforation 3 .• As a result of gastric incarceration following TDR after a period of time 4,5 .• And a rare case of TDR with laceration of stomach caused by violent cough 6 .• Iatrogenic causes are also mentioned 7 , and our case falls under this category.Large basal and apical chest tubes were left for drainage.I.V metronidazole and cephalosporin were administered to safeguard against synergistic bacteria i.e.Meleny's gangrene.As expected; postoperatively the patient's condition improved, but severe thoracotomy wound infection and dehiscence occurred due to residual empyema.With continuous occlusive dressing and repeated wound culture and change of antibiotics accordingly we managed to close the dehisced wound.

Discussion
The reported incidence of traumatic diaphragmatic rupture (TDR) after blunt truncal trauma varies between different studies 0% -8% of all hospitalized car accident victims 1,6,[8][9][10] .Most (90% --95%) of these TDR are in the left side 2 , with mortality rate that varies between 16.6 % --33.3% 1 .Complications such as visceral herniation or strangulation may arise early in patient's clinical course or remote from the traumatic event 9 .Such injuries have been treated by labarotomy or thoracotomy according to the associated organ damage 11 .Blunt TDR presents a difficult diagnostic dilemma.There is no satisfactory diagnostic tool for TDR other than having a high index of clinical suspicion 9 It has been reported as one of the most commonly missed injuries in trauma 8 .The diagnosis is more difficult in the absence of accompanying abdominal or thoracic injury, in such cases; the injury is initially, often, overlooked 12 .Initial chests radiography (CXR) or computed tomography (CT) of the chest remains the 1 st diagnostic test for most institutes with no statistical difference between the two choices as documented by recent studies 9 .Nevertheless, CT is highly recommended by some older papers 2 .Inserting a nasogastric tube may be of a great help in recognizing TDR with gastric herniation.A previous study mentioned that in a group of patients, who were surgically proven to have TDR with gastric herniation, the diagnoses was made or confirmed by inserting NG tube in six out of eight patients 13 .
Also NG tube is useful in decompressing the stomach in cases of tension gastro thorax which is a life threatening condition.Although there is an argument about this point, that the NG tube may exacerbate the condition, and it is best to use percutaneous needle decompression of the stomach throw the chest wall which is thought to be safer and more rapid 14 .During the last years thoracoscopy is introduced as one of the good choices for diagnosing the suspected cases.It is both a good diagnostic and under certain conditions, therabutic, tool.It is quickly performed, has high probability of success and cause little surgical trauma 12 .

Conclusion
Chest tube insertion whenever needed one shouldn't hesitate to put one, but only rarely indicated as emergency as in tension pneumothorax.In chest x-ray if you find a shadow in the left lower part of the chest and there is a history of blunt chest trauma; stomach herniation in the thorax is to be considered.To establish the diagnosis, an NG tube, CXR is the answer.Diaphragmatic rupture can be passed unnoticed in blunt injuries.In most cases there is no need for emergency repair, only analgesia and conservative initial management might be sufficient.Surgical repair may be done electively throw thoracotomy or labarotomy according to surgeon preference and experience.From this case we do recommend for perforated stomach in the chest to be called GASTRO-THORAX.

Fig 1 :
Fig 1: CXR showing fluid level in the stomach.

Fig 3 :
Fig 3: chest drainage bottle with gastric fluid

Fig 4 :
Fig 4: large perforation in the stomach