Ann Thorac Surg 2006;82:1908-1910
© 2006 The Society of Thoracic Surgeons
Case Reports
Gastric Rupture Associated With Diaphragmatic Hernia During Pregnancy
Theresa D. Luu, MD*,
V. Seenu Reddy, MD,
Daniel L. Miller, MD,
Seth D. Force, MD
Department of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
Accepted for publication February 22, 2006.
* Address correspondence to Dr Luu, Division of Cardiothoracic Surgery, Emory University School of Medicine, 1365 A Clifton Road NE, Suite A2100, Atlanta, GA 30322. (Email: tdluu3{at}yahoo.com).
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Abstract
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Diaphragmatic hernia complicating pregnancy rarely occurs, but it is frequently misdiagnosed. A strangulated diaphragmatic hernia in a pregnant patient presents a true surgical emergency, and delay in operative intervention can result in fetal and maternal mortality in as many as 50% of cases. We describe a case report of a pregnant patient and her fetus surviving after a spontaneous gastric rupture from a strangulated diaphragmatic hernia.
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Introduction
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Congenital or traumatic diaphragmatic hernia complicating pregnancy is extremely rare and frequently misdiagnosed. Women with this defect may be asymptomatic until pregnancy, when they present with a potentially fatal complication from a strangulated hernia [1]. The clinical features of a diaphragmatic hernia are nonspecific and include abdominal pain, nausea or vomiting, or both, dysphagia, chest pain, and dyspnea. Although the diagnosis of a strangulated diaphragmatic hernia is difficult, early recognition and intervention is critical, because delay in treatment can lead to significant morbidity and mortality [2]. We describe the first case report of a pregnant patient and her fetus surviving after a spontaneous gastric rupture from a strangulated diaphragmatic hernia.
A healthy 34-year-old primigravida woman presented to the emergency department at 33 weeks' gestation, with a 3-day history of nausea, vomiting, and back pain. She had no significant past medical history. The patient was afebrile, had a white blood cell count of 13.7, and on chest roentgenogram was found to have an infiltrate in the left lower lobe and a small left pleural effusion. She was diagnosed with pneumonia and discharged home on azithromycin.
The patient returned 8 days later with a new onset of shortness of breath and severe left-sided chest and back pain. She was afebrile and hemodynamically stable with a respiratory rate of 28, and an oxygen saturation of 96% on room air. On physical examination she had diminished breath sounds over the left hemithorax and a nontender abdomen. Significant laboratory values included a white blood cell count of 21,100 and a creatinine of 1.9. Chest roentgenogram demonstrated a large left pleural effusion (Fig 1). A chest computed tomographic scan with intravenous contrast confirmed the presence of a large left pleural effusion.
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Fig 1. Posteroanterior and lateral chest roentgenogram on the second admission, demonstrating a large left pleural effusion and gastric air-fluid level in the left hemithorax.
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The presumptive diagnosis was a left pneumonia and empyema and the patient was started on intravenous ceftriaxone and clindamycin. The thoracic surgical team was consulted and a left chest tube was placed, which drained purulent pleural fluid. Pleural fluid cultures ultimately grew alpha hemolytic streptococcus and prevotella denticola. A computed tomographic scan of the chest with oral contrast was ordered secondary to suspicion of an esophageal rupture. However, prior to the repeat computed tomographic scan, the patient went into preterm labor and had a spontaneous vaginal delivery of a healthy newborn at 34 weeks' gestation. The computed tomographic scan was performed the following day and showed extravasation of oral contrast into the left pleural space (Fig 2).
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Fig 2. Computed tomographic scan with oral contrast demonstrating extravasation of contrast into the left pleural space.
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The patient was taken urgently to the operating room for suspected esophageal rupture. Esophagoscopy, at the time of surgery, revealed a slightly edematous distal esophagus but no definitive perforation. Retroflexed view of the stomach demonstrated a twisted appearance of the fundus with erythema at the gastroesophageal junction. The patient was then explored through a left thoracotomy and a herniated portion of necrotic stomach was seen protruding through a 2-cm defect in the mid-anterior portion of the left hemidiaphragm. A radial incision was then made in the diaphragm through the defect, which revealed a necrotic portion of the cardia of the stomach with a 2-cm perforation. The stomach was then mobilized by dividing several of the short gastric vessels, and the necrotic portion of the stomach was resected and repaired primarily in two layers and then returned to the abdominal cavity. The left lung was then decorticated followed by a two-layer closure of the diaphragm. Two chest tubes were placed, the thoracotomy was closed, and the patient was taken to the intensive care unit.
The patient was kept nothing by mouth and on broad-spectrum antibiotics for 6 days. Her diet was advanced as she regained bowel function, and she was discharged to home on postoperative day 8, tolerating a regular diet. Five weeks after discharge, the patient and her infant were doing well, and the patient's chest roentgenogram showed a full expansion of both lungs and a small residual left pleural effusion.
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Comment
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The number of individuals who reach adulthood with an asymptomatic congenital diaphragmatic hernia is unknown. One study found the incidence in the adult population to be 0.17%, with a female-to-male ratio of 17 to 5 [3]. A diaphragmatic hernia can remain unnoticed until advancing pregnancy when further herniation is caused by increased stress on the diaphragm by repeated vomiting in the first half of the pregnancy, a rapidly enlarging uterus in the second trimester, and Valsalva maneuvers during labor [4]. Symptoms occur with obstruction, torsion or infarction of the herniated viscera [5]. Aside from intestinal complications, other life-threatening complications are acute dyspnea caused by compression atelectasis and mediastinal shift [6]. In cases of a Richter's hernia, such as in our report, symptoms will occur once strangulation and infarction have occurred.
Although rare, diaphragmatic hernia complicating pregnancy is accompanied with a high rate of morbidity and mortality to both the mother and the fetus. Complications due to acute herniation are more frequent during the third trimester, during delivery, and in the postpartum hours, and result in both maternal and fetal deaths in 50% of cases, and premature birth has been reported in approximately 24% of cases [1].
The timing of operative repair of the diaphragmatic hernia during pregnancy depends on the presentation of the patient. Asymptomatic patients should undergo elective surgery in the first and second trimesters to prevent further herniation of the abdominal viscera. During the third trimester, asymptomatic patients may be followed closely until fetal maturity is documented, when an elective cesarean section and hernia repair can be done simultaneously. However, if signs of obstruction or infarction are seen, then immediate repair should be undertaken. Standard vaginal delivery should be avoided in these cases because the increase in intraabdominal pressure may further displace the viscera and result in strangulation of the herniated viscus. Kurzel and colleagues [1] reported 11 of 18 of strangulated hernia occurring during labor, resulting in 5 maternal and 3 fetal deaths.
Physicians should consider the diagnosis of a strangulated diaphragmatic hernia in pregnant patients who have respiratory symptoms develop that are associated with a left pleural effusion or in patients with a history of trauma who have gastrointestinal symptoms develop. A strangulated diaphragmatic hernia in a pregnant patient is a true surgical emergency, and immediate operative intervention should be undertaken regardless of the stage of pregnancy. Delay can result in fetal and maternal mortality in as many as 50% of cases.
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References
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- Kurzel RB, Naunheim KS, Schwartz RA. Repair of symptomatic diaphragmatic hernia during pregnancy Obstet Gynecol 1988;71:869-871.[Medline]
- Hamoudi D, Bouderka MA, Benissa N, Harti A. Diaphragmatic rupture during labor Int J Obstet Anesth 2004;13:284-286.[Medline]
- Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek's hernia in a large adult population AJR AM J Roentgenol 2001;177:363-366.[Abstract/Free Full Text]
- Seon Cha A, Krew MA, Tamlyn T, Gill P. Gastric rupture associated with pregnancy Obstet Gynecol 2002;100:1072-1074.[Medline]
- Fleyfel M, Provost N, Ferreira JF, Porte H, Bourzoufi K. Management of diaphragmatic hernia during pregnancy Anesth Analg 1998;86:501-503.[Medline]
- Genc MR, Clancy TE, Ferzoco SJ, Norwitz E. Maternal congenital diaphragmatic hernia complicating pregnancy Obstet Gynecol 2003;102:1194-1196.[Medline]
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Abstract
Introduction
