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A man of 42 experienced mild epigastric pain while lifting a heavy slab in his garden and then collapsed. On admission he was afebrile, with a pulse rate of 34/min and oxygen saturation 95% on air. Breath and heart sounds were normal and his abdomen was soft with mild epigastric tenderness. The electrocardiogram showed a sinus bradycardia, which improved after administration of atropine. On the admission chest X-ray there were non-specific left basal changes (Figure 1). The epigastric pain lessened, but 12 hours later he developed severe left-sided pleuritic chest pain with respiratory distress, sinus tachycardia (160/min) and hypoxia (PaO2/8.4 kPa on air). Blood pressure was equal in the two arms (150/80 mmHg). The chest was non-tender but air entry was diminished on both sides because of fast shallow breathing. The provisional diagnosis was of acute pulmonary embolism. An isotope ventilation/perfusion scan was arranged but was abandoned when the patient's oxygen saturation declined suddenly. A CT pulmonary angiogram then showed the pulmonary vessels to be normal but multiple small-bowel loops were seen in the left chest along with a sizeable left pleural effusion (Figure 2). In the abdomen, dilated loops of small bowel suggested strangulation. At laparotomy an 8 cm linear tear was found in the posterolateral segment of the left hemidiaphragm, through which half of the small bowel had herniated and become necrotic. The diaphragmatic tear was extended and the small bowel was reduced and resected. No hernial sac was present and there were no intrathoracic adhesions. The diaphragmatic rupture was repaired in two layers with interrupted non-absorbable sutures. Later, on direct questioning, the patient was again unable to recall any thoracic or abdominal trauma.
A ‘spontaneous’ rupture implies absence of trauma, but there is always the possibility that a diaphragmatic defect arose from some forgotten trauma in the past. Increased intra-abdominal pressure from a Valsalva-like manoeuvre during heavy lifting, or pushing, may create a diaphragmatic pressure gradient sufficient to cause rupture at a pre-existing defect, whether of traumatic or structural origin.4 On Medline, only 23 cases of rupture of a hemidiaphragm without history of trauma are recorded since 1965, and associated factors have included athletics, dancing, exercise, eclampsia, labour, violent emesis, asthma and pertussis. In the present case the history and clinical features point most strongly to heavy lifting as the cause.
We thank Dr S A Kausar, Consultant Physician, for helpful comments.