Introduction

Injuries of the diaphragm once relatively uncommon are occurring more frequently paralleling the rise of frequency of automobile accidents. It occurs in 0.8%–8% of patients after blunt trauma(₁). Traumatic pericardial rupture is difficult to diagnose preoperatively but should be suspected whenever there is severe blunt chest trauma(₃). Traumatic pericardial rupture is a rare injury with potentially fatal consequences. If pericardial rupture is not recognized and treated promptly it could be fatal owing to cardiac herniation. We present an unusual case of pericardial rupture with herniation of abdominal organs and cardiohepatic adhesions.

Case report

A 41 year old multiparous (multipara) was presented for chronic post prandial epigastric discomfort , short of breath and palpitations.

She was involved in motor vehicle accident (unrestrained) during her 7th month pregnancy, five years earlier. She was admitted in a local hospital for blunt chest trauma and was discharged after delivering a still birth in stable good condition, the day after the accident. She did not undergoing any radiological investigations during her stay in the hospital.

Two years later she got pregnant again. On the 3rd trimester she started to develop upper abdominal discomfort associated with short of breath and palpitation. Despite these complaints, patient managed to complete her pregnancy safely and gave birth a full term live baby. She continued to present the same symptomatology without seeking medical consultation for another 3 years.

When she came to our attention Chest x-ray showed a suspicious air containing abdominal viscera into the” Left chest ‘ with slight shift of the cardiac silhouette to the right. Contrast upper and lower GI showed stomach and transverse colon in the ‘left chest.’

Figure 1

Figure 1: Chest-x-ray shows air containing abdominal viscera In the pericardium.

CT scan of the chest confirmed the same finding and in addition showed the herniation of left lobe of liver and omentum. The presence of the herniated viscerae in the pericardium was initially overlooked. and the diagnosis of left traumatic diaphragmatic hernia was entertained. Reviewing the CT scan of chest provided the clue and the diagnosis of intrapericardial herniation was eventually established.

Figure 2

Figure 2: multiplanar reformatted image shows the intrapericardial herniation of stomach, transverse colon and omentum

At surgery, the stomach, transverse colon and omentum were reduced through an upper laparotomy. Unlike the other herniated viscerae, the left lobe of liver was found tenaciously adherent to the diaphragmatic aspect of the right ventricle. After painstaking dissection, the heart was freed from the liver. Intra and postoperatively the cardiac function was uncompromised. There was no peritoneal diaphragm sac, but the pericardium could be seen to be grossly enlarged to accommodate the herniated viscerae.

Figure 3

Figure 3: The heart is seen through the large and transverse central tendon defect

The large transverse pericardio-phrenic (central tendon of diaphragm) defect measuring about 20 cm in length was repaired with interrupted 2/0 Prolene reinforced with prosthetic mesh.

Her postoperative course was uneventful.

Discussion

Rupture of the tendinous centre of the diaphragm and pericardium after blunt chest trauma represent a rare consequence of serious thoracic trauma (₁)

Typically, the diagnosis is established intra-operatively during resuscitation or surgery for associated injuries or at autopsy(₁,₅) It accounts about 1% of all diaphragmatic ruptures. The rupture is usually long and transverse. (₂)

However ,the gradual herniation of stomach, transverse colon, and omentum causes relatively less symptoms which become evident only months or years later. Symptoms of chronically herniating organs in the pericardium are less dramatic compared to accumulation of fluid in the pericardium.

In acute setting, if pericardial rupture is not recognized and treated promptly it could be fatal owing to cardiac herniation. Herniation of the liver into the pericardiophrenic communication and presenting with cardio-hepatic adhesions is very rare.

In our case the heart was pushed to the right to give space to the invading abdominal structures, but did not herniate intra-abdominally as it was supported and stabilized by the herniated and adherent liver from below. The patient remained with non specific symptoms until her subsequent pregnancy.

Delayed cases of diaphragmatic hernia are classically approached through the thorax because of the presence of adhesions between abdominal viscera and thoracic structures(₆).

Early surgical repair either conventionally or by minimal access surgery is necessary in order to avoid the long term sequelae of herniation including gastrointestinal obstruction, perforation, strangulation or even adhesions similar to the one we have seen in this case. CT scan can provided clues for diagnosis of intrapericardial transdiaphragmatic hernia, but was not good enough to diagnosis the cardiohepatic adhesions

Attempts to repair pericardiophrenic defect through either left or right thoracotomy , however, would have resulted unsuccessful, as the correct approach is through laparoscopy or through an upper laparotomy. (₄)

This patient did not undergo Chest-x-rays after her motor vehicle accident as most physicians and patients prefer not to undertake x-rays during pregnancy for concern of risk radiation to the fetus. Mounting evidency are showning that there may be a slight increased risk of childhood leukemia when a fetus is exposed to radiation in the first trimester, exposure is more if it occurs before the first eight weeks of gestation. It is unlikely that fetuses be affected by radiation after 15 weeks of gestation (₃)

Trauma is the leading cause of non obstetric maternal morbidity and mortality, thus it would be misguided to jeopardize the maternal safety by denying her a necessary radiological diagnostic procedure that could have helped make an early diagnosis.(₄) .Nevertheless, considerable clinical judgment and appropriate shielding is needed before exposing radiation to a pregnant woman.

Most likely, this patient sustained the rupture during her motor

Vehicle accident five years earlier and remained asymptomatic until the subsequent pregnancy, though it is reported that some women during the 4th month of pregnancy experience spontaneous rupture of the central tendon of diaphragm (₂)

Apparently her vague symptoms and subsequent pregnancy have further delayed and distracted the diagnosis of pericardial rupture and transdiaphragmatic herniation.

The aim of this report is to highlight the importance of recognizing this entity preoperatively and calls caution in the interpretation of the Chest x rays before making any decision for surgery as familiarity with the radiologic features of these lesions, and differentiation from other diaphragmatic lesions facilitates accurate diagnosis and, thus, optimal surgical approach.