Reliability of initial chest radiographs in the diagnosis of blunt diaphragmatic rupture.

BACKGROUND AND AIMS: Preoperative diagnosis of blunt diaphragamatic rupture is difficult and missed injuries can lead to severe late complications. The aim of this study was to assess the value and reliability of initial chest radiographs in diagnosing blunt diaphragmatic rupture. MATERIAL AND METHODS: A retrospective analysis of initial radiographs of 18 patients with blunt diaphragmatic rupture treated at two Greek Trauma Centers was performed. The chest radiograph was the primary diagnostic radiological tool in all of cases, and the findings were confirmed at operation in all cases. RESULTS: The preoperative diagnosis of blunt diaphragmatic rupture on the basis of chest radiographs was made in 16 out 18 patients (89%). The presence of air-containing viscera and an elevated nasogastric tube above the level of the left hemidiaphragm were the most specific signs. Although elevation of the hemidiaphragm was seen in all 18 cases, it is non-specific. A marked elevation of the right hemidiaphragm (more than 6 cm above the level of the left diaphragm), however, was a strong sign of right diaphragmatic rupture. CONCLUSIONS: In spite of the availability of newer diagnostic imaging techniques, the initial chest radiograph is very reliable in detecting most cases with blunt diaphragmatic rupture, and together with high index of suspicion and sound clinical assessment remain the cornerstone in diagnosing these challenging injuries.

Presentation of blunt small intestinal and mesenteric injuries.

During the 10 year period from 1988 to 1997, 64 patients with blunt small bowel and mesenteric injuries were treated at two trauma centres. The majority (52 cases) were victims of motor vehicle accidents, and 54% of them wore seat belts at the time of the accident. There were 22 small bowel injuries (17 full-thickness and 5 seromuscular) and 42 mesenteric injuries (7 with and 35 without a devascularised bowel segment). Shock on admission was present in 34% of the patients and generalised abdominal tenderness in 75%. Diagnostic peritoneal lavage was positive for blood in 25 out of 36 cases in which it was performed (69%), and positive for bowel content in 4/6 patients (67%) with full-thickness bowel perforations or transactions. Emergency room ultrasound was positive for blood in 13/25 cases (52%), and CT scan in 7/17 (41%). It is concluded that blunt small bowel and mesenteric injuries including patients with perforated or ischaemic bowel are difficult to diagnose using currently available diagnostic tools, and require a low threshold for exploration based on clinical suspicion in order to reduce the complications following delayed treatment of these injuries.

Blunt injuries of the stomach.

OBJECTIVE: To evaluate the results of surgical treatment of patients with blunt injuries of the stomach. DESIGN: Retrospective study. SETTING: Two general hospitals, Greece. SUBJECTS: 10 patients operated on for blunt trauma to the stomach during a 10 year period. MAIN OUTCOME MEASURES: Hospital mortality and morbidity. RESULTS: All patients were victims of motor vehicle accidents and presented with clinical signs warranting early laparotomy. There were 6 full-thickness, and 2 partial thickness gastric injuries located in the anterior wall. All injuries could be managed with simple surgical techniques without resections. Two patients bled to death on the operating table from associated injuries. All but one of the survivors had postoperative complications with a mean (SD) duration of hospital stay of 18(8) days (range 10-30). CONCLUSIONS: Blunt gastric injury is usually diagnosed at laparotomy for associated injuries but may occasionally be suspected from specific clinical findings. In most cases the injury is on the anterior wall. Simple repair is usually sufficient and the prognosis depends on the severity of the associated injuries.