LAUSR

A 20 year old male patient, with no medical history, was brought to the emergency room (ER) due to abdominal pain in the left flank which worsened with food and liquid ingestion, causing nausea and abdominal bloating/distension. The patient mentioned three such episodes, each lasting four or five days, which started about one month previously, following a basketball match. Due to worsening of the symptoms, the patient went to the emergency room. No vomiting or diarrhoea was reported. At admission, vital signs were stable. Physical examination revealed diminished breathing sounds in the left hemithorax, and epigastric tenderness. The thorax X-ray showed an image that suggested gastric contents in the left thorax (Fig. 1a). A Computer Tomography scan (CT) confirmed a massive hernia occupying two thirds of the left thorax, suggesting possible diaphragmatic rupture with right mediastinum deviation and passive lung parenchyma collapse (Fig. 1b). The patient was taken to the operation room where a laparotomy was performed. Operative findings included a left diaphragmatic lesion about 2/3 of its external portion with herniation occupying about two thirds of the left hemithorax. The stomach, spleen, splenic flexure of the colon and a portion of the omentum were found in the thorax. Hernia reduction was carried out, and the diaphragm was repaired with nylon 00 suture. The patient was transferred to the Intermediate Care Unit (ICU) for postoperatory observation and pain management. The patient was discharged seven days after surgery with no major postoperative complications. Follow-up consultations were done one week, and then one month later, with no further complaints and normal abdominal X-ray findings. Diaphragmatic injuries usually occur as a result of abdominal and/or chest trauma [1]. However, although rare, spontaneous diaphragmatic rupture (SDR) may occur, and is usually associated with increasing pressure in the abdominal cavity and chest wall without direct trauma, usually found at the oesophageal hiatus or at the points of failure of embryonic fusion of diaphragm [2, 3]. Several reports describe factors associated with SDR such as physical stress from coughing, physical exercise, vaginal delivery, vomiting, massage, static sports activities (such as pilates), patients with Ehlers–Danlos syndrome, and from local invasion by retroperitoneal liposarcoma [4]. Other authors (as Matsevych [1] and Fenner et al. [5]) suggest that the term ’spontaneous’ should be used with caution, since the cause of increased intra-abdominal pressure can be identified in several non-trauma cases, leading to a massive increase in tension of the diaphragm. The authors described the rise in the intra-abdominal pressure as the same cause of diaphragmatic rupture (DR) in blunt trauma as in non-trauma patients, with the only difference being the necessary pressure required [1, 5]. Blunt DR is also a rare condition that is usually marked by multiple-associated injuries [1]. Although some sports-related impacts may occur during the match, the patient did not mention any major trauma during the basketball match. In this case, SDR/non-traumatic DR was assumed, although this does not exclude the possibility of a blunt trauma DR. Nevertheless, spontaneous/non-traumatic or blunt diaphragmatic ruptures may be underdiagnosed since they do not have specific symptoms or signs, and are usually rare. It should be kept in mind that all of them are potentially life-threatening surgical emergencies, the management of which is exclusively surgical [1–3]. A good anamnesis leading to a suspicion of sudden increase in abdominal pressure, along with gastrointestinal or respiratory symptoms, may raise the hypothesis of DR, which could be confirmed by a simple thorax X-ray or CT scan [6]. * Rui Osório [email protected]