Traumatic diaphragmatic hernia
Introduction
Introduction to traumatic sputum Traumaticdiaphragmatichernia is a kind of spasm caused by rupture of the diaphragm in the chest and abdominal trauma, and the intra-abdominal organ protrudes into the chest through the diaphragmatic rupture. The causes of diaphragmatic rupture are various and are usually divided into two categories: direct injury and indirect injury. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific people Mode of infection: non-infectious Complications: acute diffuse peritonitis toxic shock syndrome
Cause
Traumatic sputum
(1) Causes of the disease
The causes of diaphragmatic rupture are various and are usually divided into two categories: direct injury and indirect injury.
1. Direct penetrating injury sharps, bullets and other direct penetration of the diaphragm, under the effect of pressure difference between the chest and abdomen, the abdominal organs are broken into the chest cavity by the diaphragmatic fissure.
(1) sharp stab wound: usually seen in sharp instruments (such as sharp knives) directly penetrate the diaphragm.
(2) Gunshot wounds: more common in the wartime, such as projectiles, shrapnel and other diaphragmatic penetrating injuries.
(3) iatrogenic diaphragmatic injury: caused by improper operation of multiple systems, including:
1 surgical operation caused by injury, such as low thoracic closed drainage surgery, the surgeon has insufficient experience, can directly cut the diaphragm through the intercostal incision,
2 After diaphragmatic surgery, the repair of the diaphragmatic suture in the operation is not strict, and the detachment of the knot or the postoperative rupture may cause sputum to occur.
3 chest drainage treatment of diaphragmatic muscle injury, such as chest drainage tube is too hard and placed directly on the diaphragm, long-term compression or drainage tube stimulation, corrosion caused by diaphragmatic erosion.
(4) Other injuries: The horn penetrates into the chest wall and directly penetrates the diaphragm or the instrument to penetrate the diaphragm.
2. Indirect damage to the chest and abdomen severe closed injury, can cause sudden changes in the pressure difference between the chest and the abdomen, resulting in diaphragmatic laceration and paralysis.
(1) Compression: The building collapses, the chest, the abdomen are oppressed, or other crush injuries and blast injuries, causing a sudden change in the pressure difference between the chest and the abdomen, causing the diaphragm to rupture.
(2) Deceleration: In the case of a traffic accident, the car suddenly decelerates, and the chest and abdomen are impacted and collided.
(3) Others: Excessive force is applied in an instant. If you force heavy load, load and unload heavy objects, excessive weight lifting, etc., it may cause a sudden change in the pressure difference between the chest and the abdominal cavity, causing the diaphragm to spontaneously rupture.
(two) pathogenesis
The rupture of the diaphragm caused by direct violence is mostly open injury. The size of the diaphragmatic rupture is related to the injury factor. Sharp knife stab wound, bullet penetrating injury, coal stone, iron filing damage can occur in normal or wartime, the size of the gap and The wounds are consistent. According to some scholars, 84% of the length of the crack is within 2cm. The diaphragm of the diaphragm is broken by the bullet wound. The left and right sides are similar. The rupture of the diaphragm caused by the stab wound is more common on the left side. Most people are used to holding a weapon with their right hand and it is easy to stab the other side's chest.
The diaphragmatic rupture caused by indirect violence is closely related to the size of the force. Most of the ruptures are more than 10cm. The rupture of the diaphragm can occur in any shape of the diaphragm, but there are more radial lacerations around the center of the diaphragm. Located at the junction of the ankle and the muscle (Fig. 1), the impact force is buffered on the right side due to the larger liver, and the left side is directly exposed to the abdominal cavity. Therefore, the rupture of the diaphragm is mostly on the left side, so the clinical left side trauma Sex is more common than the right side.
Magee believes that diaphragmatic rupture caused by closed injury is caused by thoracic twisting shear, while Childress believes that diaphragmatic rupture is the result of violent conduction to the diaphragm. Under normal circumstances, when the adult supine is breathing calmly, the intrathoracic pressure is exhaled. It is -5cmH20 (-0.49kPa), it is -10cmH2O (-0.98kPa) when inhaling, the abdominal pressure is 2~10cmH2O (0.2~0.98kPa), and the pressure difference between the thoracic cavity and the abdominal cavity fluctuates between 7~20cmH2O (0.691.96kPa). Between sneezing, coughing, etc., when the intra-abdominal pressure suddenly rises, the glottis immediately reflexively closes, so that the pressure in the thoracic cavity increases to counteract the intra-abdominal pressure, so as to avoid a sudden change in the pressure difference between the thoracic and abdominal cavity and damage the diaphragm muscle, such as In an emergency, severe violence suddenly oppresses the upper abdomen and lower chest, and the glottis is not closed in time, causing the lungs to be inflated and unable to antagonize the sudden increase in intra-abdominal pressure, thereby causing a sharp increase in the pressure difference between the chest and the abdomen, causing diaphragmatic tension and Rupture, therefore, any bruises, crushes, etc. that can suddenly increase abdominal pressure can cause the intra-abdominal pressure to rush to the chest cavity and act on the weak part of the diaphragm, causing the central sac to partially rupture. Abdominal visceral herniated into the chest (FIG. 2).
Direct penetrating injury The diaphragm of the diaphragm is small and easily blocked by organs such as the liver, spleen and omentum. Although there is no large amount of abdominal organs in the chest, it may have a large number of abdominal organs invading the clinical symptoms at any time. The liver, spleen, omentum and other organs are temporarily blocked, which not only affects the diagnosis but also hinders the healing of the diaphragmatic rupture. The smaller the rupture of the diaphragm is, the more likely it is to miss the diagnosis, the misdiagnosis, and even the missed diagnosis, misdiagnosis and delay of treatment, resulting in the abdominal cavity. Incarceration, necrosis and perforation, there are also reports of rupture along with the pericardium, causing pericardial tamponade. In the respiratory cycle, the contraction of the diaphragm and the pressure difference between the chest and the abdomen, the abdominal organs can be slow. Or suddenly into the chest, when the abdominal organs are not intensive, the patient may be asymptomatic. After 3 to 4 days of injury, when eating, coughing or defecation, etc., the abdominal pressure will increase, and a large number of gastrointestinal tracts will further penetrate into the chest cavity. Symptoms of digestive tract obstruction.
The diaphragmatic fistula caused by closed injury of the abdomen and the abdomen is more likely to have a splitting of the diaphragm than the direct penetrating injury. After the injury, the abdominal organs are usually inserted into the chest cavity, and the left side is traumatly invaded into the abdominal organs of the chest to the stomach or colon. More common, followed by the greater omentum, small intestine; the organ that is strangulated with the largest cross-colon, followed by the stomach, small intestine, colon spleen, descending colon, spleen is rare; the stomach into the chest, the transverse colon, the small intestine is strangulated, Necrosis and perforation can lead to severe infection of the chest, toxic shock, and traumatic paralysis on the right side. Some or all of the liver can penetrate into the chest, sometimes accompanied by transverse colon.
When the diaphragm is ruptured, a large number of abdominal organs break into the chest, resulting in:
1 ruptured diaphragmatic activity is weakened or lost, and ventilation function is reduced;
2 The affected abdominal organs broke into the chest cavity, the negative pressure disappeared, and the lungs were compressed and collapsed;
3 The abdominal organs that broke into the chest cavity moved up and down with the breathing, seriously disturbing the heart and lung function, the left and right chest cavity pressures were out of balance, the mediastinum was displaced to the contralateral side, the healthy side of the lungs was compressed, and the tidal volume was reduced;
4 The chest loses negative pressure and breaks into a large number of abdominal organs, causing the heart to be compressed and affecting the filling of the heart and normal cardiac output. The heart rate is accelerated, the blood pressure is lowered, etc., and severe cardiac arrest can occur.
5 lung insufficiency, the formation of arteriovenous short circuit in the lung parenchyma, pulmonary oxygenation decreased, so that the oxygen partial pressure decreased, further reducing the oxygen partial pressure of pulmonary blood, hypoxemia, leading to or aggravated shock;
6 atelectasis can cause and aggravate lung infection, and eventually there is a serious respiratory disorder.
Prevention
Traumatic spasm prevention
Do the regularity of tea and rice, live and live regularly, not overworked, open-minded, and develop good habits to prevent.
Complication
Traumatic hernia complications Complications Acute diffuse peritonitis toxic shock syndrome
1. The blood output of the heart reduces the negative pressure in the thoracic cavity and breaks into a large number of abdominal organs, so that the heart is compressed, the heart diastolic heart is insufficiently dilated, the blood volume is reduced, the ventricular filling is insufficient, the cardiac output is reduced, and the patient may appear. Heart rate is accelerated, blood pressure is lowered, etc., and severe cardiac arrest can occur.
2. Lung insufficiency in the chest, loss of negative pressure caused by lung insufficiency, so that the per minute ventilation decreased, pulmonary oxygenation decreased, the arterial oxygen partial pressure decreased further, the patient cyanosis, breathing difficulties increased.
3. Lung infection Insufficient lung insufficiency can cause and aggravate pulmonary infection, which can lead to severe respiratory and circulatory disorders.
4. Gastrointestinal strangulation, necrotic stomach, small intestine, colonic incarceration, blood flow disorders, can occur, narrowing, necrosis, clinical fecal occult blood or obvious melena, diffuse peritonitis and toxic shock.
Symptom
Traumatic sputum symptoms Common symptoms Heart rate is not black, coma, gastrointestinal symptoms, suffocation, shock, abdominal muscles, tension, peritonitis, pericardial tamponade
Traumatic spasm is associated with multiple sites or organs, multiple complex injuries, complex injuries, clinical symptoms and signs due to the size of the diaphragmatic rupture, the type of sacral organ implanted or how much, the gastrointestinal tract obstruction The situation of increased intrathoracic pressure and the severity of chest organ damage are different.
Chest performance
Severe pain and difficulty in breathing are the main manifestations.
(1) chest pain: diaphragmatic rupture is more reactive chest pain, 50% to 75% of patients with diaphragmatic rupture can be accompanied by rib fractures, chest pain is more severe, unbearable, and radiate to the shoulder or upper abdomen.
(2) Difficulty breathing: If the diaphragm of the diaphragm is small and blocked by organs such as the liver, spleen and omentum, the patient may have no respiratory symptoms. If the gap is large, the organs such as the stomach, small intestine and large intestine will break into the chest. As the contents of the intestine pass through the obstacle and its blood circulation disorder, the exudation increases, causing it to rapidly expand, compressing the ipsilateral lung to collapse, and pushing the mediastinum to the healthy side, the expansion of the contralateral lung is also affected, and the tidal volume Reduced, combined with paralysis of the diaphragmatic muscles of the affected side, decreased ventilation, patients with dyspnea, cyanosis, hypoxemia, decreased or disappeared respiratory sounds on the affected side, and chest sounds and bowel sounds.
2. Abdominal performance
(1) peritoneal irritation: due to upper abdominal injury, diaphragmatic rupture, rib fracture pain, upward abdominal radiation, bloody fluid stimulation of the peritoneum, etc., patients have upper abdominal pain, tenderness, abdominal muscle tension, due to a large number of abdominal organs into the chest Abdominal emptiness, abdominal examination can be flat or scaphoid, when the diaphragmatic rupture and hemorrhage flow into the abdominal cavity or combined with abdominal organ damage, the puncture can draw hemorrhagic fluid.
(2) Abdominal organ injury performance: According to literature statistics, about 15% of traumatic spasticity is accompanied by gastrointestinal damage, 30% to 35% with spleen rupture, 9% to 20% with liver damage, so A considerable number of patients with traumatic paralysis may have symptoms and signs of abdominal cavity organ or substantial organ damage. Cavity organ damage is mainly characterized by symptoms and signs of peritonitis. Substantial organ damage is mainly manifested as intra-abdominal hemorrhage. Or hemorrhagic shock.
3. Intestinal obstruction symptoms
If the diaphragmatic rupture is small and the gastrointestinal tract is not much, some patients may present with chronic, incomplete intestinal obstruction, such as sternal, upper abdomen, lower abdomen and left chest discomfort, eating, supine or left lateral position. Intensification, vomiting or venting reduces the inflated visceral flatulence, and the pain is relieved. Many patients are relatively stable after active rescue treatment. After a period of time (several days or days 10 days), due to eating, getting out of bed, When the abdominal pressure is increased due to defecation, etc., a large number of abdominal organs are invaded into the chest cavity, and the patient has acute, complete intestinal obstruction symptoms, which are abdominal pain, vomiting, cessation of exhaust and defecation, stomach, small intestine, and colonic incarceration. At the time, there may be fecal occult blood or obvious black stool, the intestinal tube is narrowed, and the necrosis may lead to serious infection of the chest and the condition deteriorates.
If the diaphragmatic rupture is large and a large number of gastrointestinal tracts break into the chest, symptoms of acute intestinal obstruction appear immediately after the injury.
4. Other symptoms, signs
(1) Complicated injury: Traumatic hernia is often accompanied by rib fractures, abdominal organ damage, there are 20% to 50% of patients with pelvic fractures, nearly 30% with limb fractures, 18% ~ 30% with craniocerebral trauma, nearly 10% with spinal fractures and kidney damage, some patients are even accompanied by pericardial laceration or heart blunt contusion, so many patients can be accompanied by corresponding fractures, heart, kidney and brain Injury performance: 1 heart blunt trauma: may have arrhythmia, abnormal ECG; 2 pericardial laceration: abdominal organs can be filled with pericardial tamponade after pericardial; 3 kidney damage can have hematuria; 4 brain injury can have coma, etc. .
(2) shock: due to blood loss, blood pneumothorax, a large number of abdominal organs into the chest cavity, the loss of negative pressure, the displacement of the heart and large blood vessels, etc., resulting in decreased blood volume and discharge, rapid traumatic and / or blood loss Sexual shock, when strangling necrosis occurs in the organ, it causes serious infection and toxic shock. The patient has heart rate acceleration, blood pressure drop, pulse pressure difference is reduced, and urine is less.
5. Clinical staging
(1) acute phase: after the injury to the initial stage of stable disease, indirect violence caused by diaphragmatic laceration, large gap and a large number of abdominal organs into the chest, or with varying degrees and different numbers of rib fractures, pelvic fractures, Limb fracture, spinal fracture, craniocerebral injury, kidney injury, spleen rupture, liver injury, digestive tract injury, this period mainly manifested as severe chest, abdominal pain, difficulty breathing, circulatory disorders.
(2) Intermittent or chronic phase: About 1/3 of the patients have a small diaphragmatic rupture, the diaphragmatic rupture is temporarily blocked by the abdomen into the organ (such as obstruction of the omentum), or a small part of the organ is invaded or has not yet entered the chest. The injury was relatively mild, and no chest X-ray examination was performed. The diaphragmatic rupture and spasm were not found in time. After active rescue treatment, the condition was stable and entered intermittent or chronic stage. The gastrointestinal symptoms were prominent in this period. After the sternum, abdominal or left chest pain, discomfort, eating into the stomach, supine or left lateral position, the pain is intensified, due to the number of digestive tracts, pressure or incarceration, patients may have intermittent episodes of intestinal obstruction, vomiting, After inhalation or venting, it is invaded into the intestinal lumen, and the swelling is relieved. The symptoms of intestinal obstruction can be relieved to varying degrees. The incarcerated gastrointestinal mesenteric vessels are stressed more severely. When the blood supply is disordered, fecal occult blood may occur. Obviously black.
(3) Obstruction or strangulation period: Because the diaphragm is moving up and down with the breathing, the crack is affected by many factors such as the obstruction of the omentum or the intestine, and the diaphragm of the diaphragm is not easy to heal itself, about 75% of the patients. Three months after the injury, 85% of the patients aggravated the symptoms within 3 years and the sputum content was narrowed. When the patient passed the acute phase, after several days or months of intermittent or chronic phase, when the activity, defecation, coughing When the abdominal pressure increases, a large number of organs in the abdominal cavity further penetrate into the chest cavity, and acute intestinal obstruction, dyspnea, pleural effusion, etc., digestive tract stenosis, necrotic perforation, pneumothorax, severe chest infection, toxic Shock symptoms.
Examine
Traumatic spasm
Acute traumatic white blood cells are normal or elevated.
X-ray inspection
(1) Thoracic fluoroscopy or plain film: X-ray fluoroscopy or plain film examination is the most reliable and most common diagnostic method for traumatic sputum. Some of the ruptures are small and are blocked by the liver, large omentum or very few organs. Early chest radiographs may be normal or almost normal, but as the disease progresses, 75% of patients may have abnormal changes, and their common abnormal X-ray changes are:
1 left iliac muscle is elevated;
2 abnormal shadows appear above the level of the diaphragm, such as gastrointestinal shadows in the chest, stomach, intestinal air-liquid level or dense shadow;
3 heart, mediastinal image shift to the healthy side;
4 lung collapse, discoid lung atelectasis;
5 The fluid level appears in the affected side of the chest;
6 patients may have signs of rib fracture.
Due to the different abdominal organs that break into the chest, the X-ray findings of traumatic hernia are more complicated:
1 , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ;
2 When the organ that is invaded is the transverse colon and incarceration and strangulation, the appendix may appear like a gastric sac due to the expansion of the colon. It should be differentiated from the gastric vesicle, usually the pseudo-stomach formed by the expansion of the colon. The bubble is farther from the diaphragm, and the real stomach bubble is close to the armpit;
3 right iliac rupture of the liver into the right chest, X-ray signs have three types, type I: the entire liver into the chest, the liver is a high-level smooth arch image, similar to the right semitendinosus elevation, easily misdiagnosed as ,, type II: part of the liver into the right chest cavity, there is a convex image above the right iliac crest, type III: in addition to the liver is accompanied by the gastrointestinal part into the right chest cavity, the X-ray signs in addition to liver shadows Images of the stomach, intestines, and varying degrees of atelectasis and pleural effusion.
(2) Digestive tract angiography: In patients with acute phase, if there is suspected traumatic spasm, if there is no contraindication, the stomach tube can be inserted from the nasal cavity. Under X-ray fluoroscopy, the gastric tube is seen above the normal plane of the diaphragm and spiraled, or through the stomach tube. Inject 60-90 ml of Gastrografin to show the stomach in the chest, and the diagnosis can be confirmed.
If the patient's condition is stable or in the intermittent period, it is feasible to have a digestive tract barium meal or barium enema examination, especially in the stomach of the chest, small intestine, colonic incarceration, and more accurate diagnosis.
1 upper digestive tract barium meal examination can be seen: the esophagogastric junction and the gastroduodenal junction shortened or adjacent, the stomach curvature can be above the small curvature of the stomach, the normal relationship is reversed;
2 enema examination showed that the sputum and sputum of the colon in the incarcerated section were juxtaposed on the plane of the diaphragm, which was narrowed by the incarceration. It was funnel or beak. When the colon was completely obstructed, the shadow of the spleen was observed. Sudden interruption, or a small amount of tincture from the bottom up into the colon cavity above the diaphragm, if the obstruction is incomplete, it can be seen that the expectorant continues to flow into the chest of the chest, and then into the intra-abdominal colon.
(3) artificial laparoscopic angiography: used to diagnose the right semitendinosus rupture or sputum, after the pneumoperitoneum, the sputum patient standing chest radiograph, if there is rupture of the diaphragm or traumatic paralysis, the gas in the abdominal cavity can enter the chest cavity, according to Polychronidis reported that most patients used this method to make a timely diagnosis. Chistiansen used artificial pneumoperitoneum to examine 9 patients, 7 patients did not find gas into the chest, and surgery confirmed no rupture of the diaphragm.
(4) CT scan: Killeen et al. and Murray et al reported that CT scan can determine the location of hernia and the nature of invading the thoracic organ. As an auxiliary diagnostic measure, the sensitivity is 61%-71% and the specificity is 87%. ~100%, Bergin et al reported that 80% of patients can observe diaphragmatic defects, 60% of patients can show visceral intrusion into the chest, and its CT signs are:
1 continuity of the diaphragm muscle is interrupted;
2 abdominal cavity visceral into the chest, such as the intestine fistula into the chest and its collar sign, the right side of the liver can be seen in the upper third of the liver and the posterior wall of the chest, while the left side can show the stomach, intestine Close to the left chest wall, CT scan in the supine position, it can be seen that the abdominal cavity of the chest cavity fell into the chest due to the loss of the ruptured diaphragm support, and the posterior chest wall.
2. B- ultrasound Ultrasound images can show the continuity of the diaphragm, and can detect the liver, spleen and other organs that break into the chest.
3. Thoracoscopy X-ray examination of undiagnosed patients, can be used for thoracoscopic examination, Jackson et al reported that for patients with left lower thoracic penetrating injury, thoracoscopic examination can help to determine the presence or absence of diaphragmatic rupture and traumatic paralysis. The diagnosis rate is nearly 100%, and the blood and blood clots can be removed at the same time, hemostasis can be repaired, the lung laceration and diaphragmatic rupture can be repaired, and some unnecessary thoracotomy can be avoided. It is considered that the examination should be carried out within 24 hours.
4. Radioactive gold and liver scans for the diagnosis of the right side of the traumatic hernia, liver intrusion can be helpful.
Diagnosis
Trauma diagnosis
Diagnostic criteria
In the early stage, because of the complex injury and serious injury, it affects or masks the rupture of the diaphragm and the symptoms and signs of sputum formation. Clinicians often only pay attention to the clinical manifestations of breathing, circulation and digestive system, satisfying the diagnosis of abdominal organ injury, blood gas chest and so on. Even the chest body dilated into the thoracic cavity is misdiagnosed as tension pneumothorax, when the lungs are compressed, the lungs collapse, misdiagnosed as pneumonia, atelectasis, etc., neglecting the possibility of sputum, due to chronic patients Gastrointestinal symptoms are more prominent. Most patients show post-sternal, abdominal or left chest pain and discomfort. In the diet, supine or left lateral position, the pain is aggravated and often misdiagnosed as post-traumatic adhesive intestinal obstruction or inflammatory bowel obstruction. Peptic ulcer, gallbladder disease or coronary insufficiency heart disease, etc., and corresponding treatment, many patients appear intestinal obstruction symptoms several days or even months after the injury, after the occurrence of acute intestinal obstruction or strangulation symptoms, not Less patients were misdiagnosed as acute strangulated intestinal obstruction and exploratory laparotomy. Some authors reported that after traumatic hernia had intestinal obstruction symptoms, emergency section Surgery has not been able to determine the cause, only to be diagnosed in the chest drain after a bowel movement.
Differential diagnosis
1. Tension pneumothorax Thoracic fluoroscopy shows that when gas is single, attention should be paid to the differentiation of gastric intrusion and tension pneumothorax.
2. Pneumonia, pulmonary atelectasis shows increased lung density, attention should be paid to lung compression, lung collapse and pneumonia, and atelectasis.
3. Post-traumatic adhesion intestinal obstruction, inflammatory bowel obstruction, peptic ulcer, gallbladder disease and insufficient blood supply to the coronary artery. Patients with chronic gastrointestinal symptoms are prominent. Most patients show post-sternal, abdominal or left chest pain and discomfort. Eating, supine or left lateral position, the pain is intensified, should be noted.
