Case Reported In Puerto Rico Reveals Suspicion Of Hepatothorax In Patients With a History Of Trauma

This is the first case reported in the medical literature.

Coronal thoracoabdominopelvic computed tomography. Photo: Case Report. Science Magazine.

This is the first case reported in the medical literature from the Ponce Health Sciences University, Ponce, Puerto Rico and the Mayagüez Medical Center, Mayagüez, where a patient presented a rare case of hepatothorax late for diaphragmatic injury right with a rip 13 years old after a car accident trauma, which he presented as gastritis isolated without any type of respiratory symptomatology.

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Due to the broad clinical nature of hepatothorax due to late diaphragmatic hernias, it requires that each case be managed individually, and the index of clinical suspicion for hepatothorax should be maintained for all patients with a history of trauma.

“Our patient had an unusual presentation of a hepatothorax that exhibited only gastrointestinal symptoms and no respiratory distress or discomfort, a case like ours has not yet been reported in the literature. Physicians should consider this clinical case when suspecting a possible diagnosis of diaphragmatic hernia delayed traumatic injury that can be complicated by a hepatothorax”, they indicate.

case presentation

It was a 32-year-old male graphic designer, who came to the general surgeon for an external consultation referred by his gastroenterologistwith symptoms of epigastric pain and abdominal discomfort that has been on and off for about 13 years.

The specialists of the case published in the journal Science emphasize that the psychosocial history of the patient revealed substance abuse in the past, including alcohol and cannabis. Surgical history is significant for lithotripsy, parathyroidectomy, open reduction with internal fixation, and hemorrhoidectomy. Past medical history is notable for a car accident that occurred 13 years ago.

A computed tomography The thoraco-abdominopelvic examination showed four fractured right lower ribs and a three-part acetabular fracture, although the CT scan at the time showed no evidence of other relevant pathology.

The patient’s gastritis had remained refractory to treatment and had worsened, encouraging the patient to address the complaint with a general surgeon. The patient was not in acute distress at this time. Wall inspection showed asymmetric chest expansion. In particular, the right hemithorax had decreased movement compared to the left.

Cross-sectional view of the thoracic cavity. Photo: Case Report. Science Magazine.

“The patient reports that his symptoms remained refractory to medical treatment and worsened over time. Chest wall inspection showed asymmetric chest expansion and decreased movement of the right hemithorax compared to the left. Cardiorespiratory auscultation was significant for grunting in the second right intercostal space and reduced breath sounds in the region of the right lower lobe of the lung compared to the left side,” the Puerto Rican specialists explain.

Treatment and solution of the case

Taking into account the symptoms of this patient and the findings in the physical examination and incidental findings in images; in combination with a significant traumatic event that occurred 13 years earlier, coinciding with the onset of the patient’s symptoms, it was concluded that this patient’s presentation was consistent with a diagnosis of a delayed right traumatic diaphragmatic hernia with hepatothorax.

Once the diagnosis was established, the patient was recommended a thoracotomy with right-sided diaphragmatic hernia repair. Given his stable clinical picture, absence of obstructive symptoms and respiratory difficulties, the patient was scheduled for elective repair surgery with the general surgeon.

“A case like ours has not been reported in the literature and physicians should take this case report into consideration when suspecting a possible diagnosis of late traumatic diaphragmatic hernia that may be complicated by hepatothorax. We recommend maintaining a high index of clinical suspicion for hepatothorax due to delayed traumatic diaphragmatic hernia for all patients with a history of trauma,” they explained.

Under general anesthesia, a lateral thoracic incision was made at the right seventh intercostal space. Intraoperatively, the cavity was entered, and the right traumatic diaphragmatic hernia with hepatothorax was confirmed.

View of the diaphragmatic defect after reducing the liver and intestine to the abdominal cavity. Photo: Case Report. Science Magazine.

Three months later, a follow-up abdominopelvic computed tomography scan was performed, which revealed the absence of an abdominal hernia contained within the thoracic cavity. Six months later, the patient has been in perfect condition and reported that all gastrointestinal symptoms associated with the traumatic diaphragmatic hernia have resolved.

Access the case here.

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