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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 208-211

Traumatic diaphragmatic rupture with liver laceration in a 2-year-old child after blunt abdominal trauma: A case report


1 DivisionofPediatricCriticalCare,ChaitanyaHospital, Chandigarh, India
2 Department of Pediatrics, Chaitanya Hospital, Chandigarh, India
3 DivisionofPediatricSurgery,ChaitanyaHospital,Chandigarh, India

Date of Submission24-Apr-2021
Date of Decision28-May-2021
Date of Acceptance07-Jun-2021
Date of Web Publication10-Jul-2021

Correspondence Address:
Dr. Navdeep Dhaliwal
DepartmentofPediatricCriticalCare,ChaitanyaHospital,Sector44-C,Chandigarh-160047
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_36_21

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  Abstract 


Diaphragmatic rupture after blunt abdominal trauma is a rare entity in pediatric age group. We report a 2-year-old child who presented to us with respiratory distress after he fell from bike. Initial evaluation had a suspicion of pneumothorax, but computed tomography scan confirmed that he had a diaphragmatic tear along with herniation of abdominal contents in left hemithorax. The child was managed successfully with open surgical approach. Since there are no specific signs and symptoms to diagnose this condition, high index of suspicion should be kept in all cases of abdomino-thoracic injuries.

Keywords: Liver laceration, pediatric trauma, traumatic diaphragmatic rupture


How to cite this article:
Dhaliwal N, Grover A, Dharmik A. Traumatic diaphragmatic rupture with liver laceration in a 2-year-old child after blunt abdominal trauma: A case report. J Pediatr Crit Care 2021;8:208-11

How to cite this URL:
Dhaliwal N, Grover A, Dharmik A. Traumatic diaphragmatic rupture with liver laceration in a 2-year-old child after blunt abdominal trauma: A case report. J Pediatr Crit Care [serial online] 2021 [cited 2021 Sep 19];8:208-11. Available from: http://www.jpcc.org.in/text.asp?2021/8/4/208/321102




  Introduction Top


Traumatic diaphragmatic rupture (TDR) is a rare injury, with only a few cases reported in pediatric age group. TDR with liver laceration is even more rare. Its diagnosis can be difficult in the acute phase of trauma because its signs are not specific, especially in a polytrauma context. Of all pediatric trauma cases, the prevalence of TDR is 0.07%. The incidence in blunt abdominal trauma is around 3% with very few cases in penetrating injuries.[1],[2],[3]

Surgeons usually follow a selective nonoperative approach for most of the intraabdominal organ injuries, but TDR warrants an immediate surgery as there is risk of bowel strangulation and infarction. Missing this important injury can lead to devastating consequences by increasing mortality rate from 20% up to 80%.[4]

The most common symptoms reported are dyspnea (86%) and abdominal pain (13%) along with decreased breath sounds on the affected side (73%).[5] Diagnostic evaluation includes laboratory tests, sonography, and computed tomography (CT) scan but majority of the time, the diagnosis gets established at the time of laparotomy.[6]

Management of pediatric trauma patients poses different challenges. Compared to adults, children usually have an unreliable abdominal examination because of either an associated head injury, low Glasgow Coma Scale or due to excessive crying and abdominal distension.[7]

Here, we want to emphasize the importance of early diagnosis and treatment of (TDR) rupture which is an uncommon but potentially life-threatening problem and is usually associated with other intra-abdominal injuries.


  Case Report Top


We present a 2-year-old male baby who came in our emergency after falling from motorbike when he was sitting in his grandmother's lap at the back seat. The baby was crushed under grandmother and bike.

He was admitted 4 h after trauma in unstable condition. He was lethargic, tachypneic with respiratory rate of 68/min, heart rate 176/min, Spo2 on room air was 84%–86%, and blood pressure 98/60. Primary survey revealed that his airway was intact but was having visible signs of respiratory distress. Rapid assessment was done to pick up any life-threatening or limb-threatening injuries which revealed bruises over right hand, B/L ankle, over right hypochondrium, and swelling on right elbow.

Respiratory examination revealed intercostal and subcostal recessions, paradoxical breathing pattern, with grunting. Auscultation revealed diminished air entry on left side. Abdominal examination showed liver 6 cm below right costal margin with tender margins. There was no guarding/rigidity in rest of the abdomen.

He was started on non invasive ventilation by humidified high flow nasal cannula (HHFNC) settings of 25 l/50% FiO2. Initial blood investigations revealed metabolic acidosis with pH 7.3 bicarb 15, Hb 10.6 g/dl, leukocytosis of 15,900, transaminitis with aspartate aminotransferase 2390 U/L, and alanine aminotransferase 1710 U/L. Amylase, lipase, creatinine, coagulation profile all were in normal range. His Focused Assessment with Sonography for Trauma (FAST) scan was negative. Head CT and limb X-rays were unremarkable. Initial Chest X-ray (CXR) was having a suspicion of left loculated pneumothorax and doubtful bowel loop opacities in lower zone, so CXR was repeated with Ryle's tube in situ which revealed stomach lying in left hemithorax suggestive of TDR or an eventration of diaphragm [Figure 1] and [Figure 2]. CT chest was done which finally confirmed stomach and left lobe of liver in left hemithorax along with small hemothorax and a diaphragmatic tear.
Figure 1: Chest X-ray showing mediastinal shift to right. Large air-filled space in left mid and lower zone, along with ill-defined left dome of diaphragm

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Figure 2: Chest X-ray with Ryle's tube in situ confirms stomach in left hemithorax

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Laparotomy was done which showed 100 ml blood in left hemithorax, complete left diaphragmatic tear around 8 cm, left lobe of liver, spleen, stomach and transverse colon in left hemithorax along with superficial laceration on liver, pericardium was also visible but without any tear [Figure 3] and [Figure 4]. Postoperative period was managed in pediatric intensive care unit and was uneventful. Feeds were started after 3 days, and the child was discharged on day 7 and is doing well in follow-up.
Figure 3: Intraoperative pictures showing hemothorax, large rent in left diaphragm, spleen, left lobe of liver, transverse colon, and stomach in left hemithorax

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Figure 4: Intraoperative pictures showing hemothorax, large rent in left diaphragm, spleen, left lobe of liver, transverse colon, and stomach in left hemithorax

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  Discussion Top


While head and thoracic trauma account for most death and disability in children, abdominal injuries constitute the most common unrecognized cause of death. 90% cases of abdominal trauma in children are blunt in nature. Common mechanisms include road traffic accidents, falls, pedestrian injuries, bicycle injuries, and nonaccidental trauma. Penetrating injuries are much less common in children than in adults.[7]

The incidence of TDR in children is very low, however, compared to adults, this phenomenon occurs more frequently in pediatric population.[8] It might be because of the anatomical variation in children such as the thin abdominal wall and more elastic thoracic cage causing an increased propensity to develop diaphragmatic rupture and subsequent herniation.[9] Blunt rupture of the diaphragm is uncommon, occurring in approximately 3% of patients with abdomino-thoracic trauma.[10] Greater than 60% of diaphragmatic ruptures are on the left side, while less than 5% are bilateral.[11],[12] Its because left dome is devoid of the protection by liver.

A key factor when managing such cases of suspected TDR is the time to diagnosis. A literature review in children showed that in only 58.4% cases, diagnosis was established with in first 24 h which could be the cause of delayed interventions.[13] Another study in adults from Egypt found that only 40% of their patients were diagnosed before surgical intervention.[6] Diagnosis remains difficult because diaphragmatic rupture is often associated with other visceral injuries that may mask the clinical or radiological signs. Since there is no gold standard investigation for early and reliable diagnosis, this life-threatening injury is often overlooked. Early diagnosis is based on a high index of clinical suspicion and may require repeated radiological studies as is highlighted in our case also. While X-ray is a one-dimensional modality in which there will be summation of tissues and bowel gas or pneumothorax both can look similar, ultrasonography (USG) is usually operator dependent, and unless the clinician specifically tells the radiologist to look for TDR, the usual probe angulation might miss it. Moreover, the FAST technique looks more into abdominal visceral integrity and fluid rather than diaphragm. CT scan has the disadvantage of high radiation exposure and might not be available at all places, but it will definitely pick up TDR, and in addition, it can tell about fracture, contusion, herniation etc. Hence, where CT is not available, a combination of X-ray and USG can be helpful where we ask the radiologist to specifically look for it.

Traumatic diaphragmatic injury itself is rarely lethal at initial presentation, however, associated injuries and complications of untreated TDR such as herniation, strangulation, and perforation of abdominal viscera or inadvertently putting intercostal drainage tube (ICD) will have disastrous clinical consequences.

In our case, also, the first CXR had a suspicion of pneumothorax but ICD insertion was not done as we were doubtful about TDR and CT chest finally confirmed the diagnosis.

Blunt TDR is a rare condition in children. Early diagnoses are based on high index of clinical suspicion and when in doubt always do a repeat imaging in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given consent for images and other clinical information to be reported in the journal. The patient's parents understand that the names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ramos CT, Koplewitz BZ, Babyn PS, Manson PS, Ein SH. What have we learned about traumatic diaphragmatic hernias in children? J Pediatr Surg 2000;35:601-4.  Back to cited text no. 1
    
2.
Shehata SM, Shabaan BS. Diaphragmatic injuries in children after blunt abdominal trauma. J Pediatr Surg 2006;41:1727-31.  Back to cited text no. 2
    
3.
Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: Prompt identification and early management of serious and life-threatening injuries. Part II: Specific injuries and ED management. Pediatr Emerg Care 2000;16:189-95.  Back to cited text no. 3
    
4.
Payne JH Jr., Yellin AE. Traumatic diaphragmatic hernia. Arch Surg 1982;117:18-24.  Back to cited text no. 4
    
5.
Karnak I, Senocak ME, Tanyel FC, Büyükpamukçu N. Diaphragmatic injuries in childhood. Surg Today 2001;31:5-11.  Back to cited text no. 5
    
6.
Abdelshafy M, Yusuf SE. Khalifa, Traumatic diaphragmatic hernia challenging diagnosis and early management. J Egypt Soc Cardio-thoracic Surg 2018;26:219-27.  Back to cited text no. 6
    
7.
Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: Prompt identification and early management of serious and life-threatening injuries. Part I: Injury patterns and initial assessment. Pediatr Emerg Care 2000;16:106-15.  Back to cited text no. 7
    
8.
Furák J, Athanassiadi K. Diaphragm and transdiaphragmatic injuries. J Thorac Dis 2019;11 Suppl 2:S152-7.  Back to cited text no. 8
    
9.
Rance CH, Singh SJ, Kimble R. Blunt abdominal trauma in children. J Paediatr Child Health 2000;36:2-6.  Back to cited text no. 9
    
10.
Simpson J, Lobo DN, Shah AB, Rowlands BJ. Traumatic diaphragmatic rupture: Associated injuries and outcome. Ann R Coll Surg Engl 2000;82:97-100.  Back to cited text no. 10
    
11.
Athanassiadi K, Kalavrouziotis G, Athanassiou M, Vernikos P, Skrekas G, Poultsidi A, et al. Blunt diaphragmatic rupture. Eur J Cardiothorac Surg 1999;15:469-74.  Back to cited text no. 11
    
12.
Montresor E, Mangiante G, Vassia S, Barbosa A, Attino M, Bortolasi L, et al. Rupture of the diaphragm caused by closed trauma. Case contributions and review of the literature. Ann Ital Chir 1997;68:297-303.  Back to cited text no. 12
    
13.
Marzona F, Parri N, Nocerino A, Giacalone M, Valentini E, Masi S, et al. Traumatic diaphragmatic rupture in pediatric age: Review of the literature. Eur J Trauma Emerg Surg 2019;45:49-58.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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