article · International Journal of Surgery Case Reports
Penetrating diaphragmatic injuries can easily be overlooked, and diagnostic delays carry severe risks of visceral herniation, contamination, and fatal sepsis. A clinical case from Ethiopia describes a 21-year-old man who presented six days after sustaining a posterior stab wound. Initially treated at a primary hospital with a chest tube for suspected hemopneumothorax, he was later referred in a state of septic shock with enteric contents draining from the tube. Emergency laparotomy revealed a twelve-centimetre diaphragmatic rupture with herniation of multiple abdominal organs, splenic laceration, and gastric perforations. Although the organs were reduced, the perforations repaired, and broad-spectrum antibiotics administered, the patient died eleven days after surgery from refractory septic shock and multiorgan failure. The case underscores the diagnostic pitfalls caused by limited computed tomography access and delayed referrals.
Traumatic stab wounds that pierce the diaphragm are difficult to detect early, especially when advanced imaging tools like computed tomography are unavailable. Delays in recognising these injuries allow stomach and bowel contents to leak into the chest cavity, triggering severe infections. Understanding these clinical warning signs helps frontline healthcare workers identify complications sooner and refer patients before irreversible damage occurs.
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Introduction and importance: Traumatic diaphragmatic injury following penetrating trauma is uncommon and easily overlooked; delayed diagnosis may lead to visceral herniation, perforation, contamination, and sepsis. Case presentation: A 21-year-old man presented 6 days after a posterior stab wound, referred from a primary hospital where a chest tube had been inserted for suspected hemopneumothorax. He was hypotensive, febrile, and hypoxic, with reduced left air entry, bowel sounds in the chest, and gastrointestinal contents draining through the tube. A chest radiograph showed a large left intrathoracic air-fluid level with mediastinal shift. Emergency laparotomy revealed a 12 cm left posterior diaphragmatic defect; herniation of the stomach, jejunum, transverse colon, and spleen; two gastric fundal perforations; and a grade I splenic laceration. The viscera were reduced; the gastric perforations were repaired in two layers with omental reinforcement; the diaphragm was closed primarily; and lavage was performed. Re-look laparotomy on postoperative day 2 confirmed intact repairs and drained a left subphrenic collection. Despite norepinephrine support and escalation from ceftriaxone/metronidazole to vancomycin/meropenem, he died on postoperative day 11 from refractory septic shock and multiorgan failure. Clinical discussion: This case highlights diagnostic pitfalls of delayed penetrating diaphragmatic injury, the significance of enteric chest-tube drainage, and the impact of referral delay and limited CT availability. Conclusion: Early suspicion, rapid transfer, and prompt operative source control are essential after thoracoabdominal stab wounds with suspected diaphragmatic injury.
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DOI: 10.1097/rc9.0000000000000815
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