A stress ulcer duodenal perforation complicating diaphragmatic rupture with multiple bone fracture in a polytrauma patient due to fall from a tree

Authors

  • Sudhir Kumar Panigrahi Department of Surgery, Kalinga Institute of Medical Sciences, KIIT, Bhubaneswar, Odisha, India
  • Amaresh Mishra Department of Surgery, Kalinga Institute of Medical Sciences, KIIT, Bhubaneswar, Odisha, India
  • Pradipta Kishore Khuntia Department of Surgery, Kalinga Institute of Medical Sciences, KIIT, Bhubaneswar, Odisha, India
  • Abinash Kanungo Department of Surgery, Kalinga Institute of Medical Sciences, KIIT, Bhubaneswar, Odisha, India

DOI:

https://doi.org/10.18203/2349-2902.isj20181617

Keywords:

Diaphragmatic rupture, ICU care and prolonged morbidity, Multiple bone fracture, Polytrauma due to fall, Stress induced duodenal perforation

Abstract

Polytrauma in a 55 years male due to blunt trauma like fall from a height involving fracture of long bones, undisplaced fracture pelvis, fracture multiple ribs with a preliminary diagnosis of eventration of the hemidiaphragm in a apparently hemodynamically stable patient with a normal CT scan of brain, though poses a major physiological challenge, however runs a better prognosis. But with the passing of hours as patient develops respiratory distress and chest and abdomen CECT confirms a large lacerated hemidiaphragm with herniation of abdominal visceras occupying the hemithorax with lung collapse, alarms the gravity of the injury. An uncommon stress ulcer duodenal perforation on the 2nd day of admission with ensuing pyoperitoneum further threatens the hemodynamics and enhances the morbidity and mortality. This warrants an active and prompt action by multispecialty involvement. Emergency laparotomy to address the pyoperitoneum, closure of the duodenal perforation, reduction of the herniated abdominal visceras from the hemithorax, thorough saline lavage of the abdominal and involved chest cavity, placement of intrathoracic chest tube drain, repair of the lacerated diaphragm, placement of peritoneal cavity drains and closure of the abdomen settles the issue of damage control surgery in this case. Postoperative care in the ICU with ventilator support, higher antibiotics and supportive medications, repeated laboratory and radiological tests helps in overcoming the hemodynamic crisis in such critically ill patients. Our patient subsequently developed pneumonitis and had a postoperative protracted course in the ICU and finally shifted to the general ward on 7th day of his admission.  

References

Nchimi A, Szapiro D, Ghaye B, et al. Helical CT of blunt diaphragmatic rupture. AJR Am J Roentgenol. 2005;184(1):24-30.

Dietrich P, Alsofrom G: The diaphragm. In Radiology: diagnosis, imaging, intervention. Volume 1. 1st Ed; Philadelphia: Lippincott;1990:1-10.

Shah R, Sabanathan S, Mearns AJ, Choudhury AK, Traumatic rupture of diaphragm, Ann Thora Surg. 1995;60(5):1444-9.

Eren S, Kantarcı M, Okur A. Imaging of diaphragmatic rupture after trauma. Clin Radiol, 2006;61(6):67-77.

McNamara JJ, Paulson DL, Urschel HC, Razzuk MA: Eventration of the diaphragm. Surg. 1968, 64(6):1013-21.

J. L. Cameron, “Diaphragmatic injury,” in Current Surgical Therapy, 7th Ed, Louis, Mo, 2001.1095-100

O. F. Grimes, “Traumatic injuries of the diaphragm. Diaphragmatic hernia, Am J Surg.1974;128 (2):175-81.

Walchalk LR, Stanfield SC. Delayed presentation of traumatic diaphragmatic rupture. J Emerg Medi. 2010;39(1):21-4.

Larici AR, Gotway MB, Litt HI, Reddy GP, Webb WR, Gotway CA., et al. Helical CT with sagittal and coronal reconstructions: accuracy for detection of diaphragmatic injury. AJR Am J Roentgenol 2002;179(2):451-7.

Selye H. The general adaptation syndrome and the diseases of adaptation. J Clin Endocrinol Metab 1946;6(2):117-230.

Lucas CE, Sugawa C, Riddle J, Rector F, Rosenberg B, Walt AJ. Natural history and surgical dilemma of “stress” gastric bleeding. Arch Surg 1971;102(4):266-73.

Cook D, Heyland D, Griffith L, Cook R, Marshall J, Pagliarello J. Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechani-cal ventilation. Crit Care Med. 1999;27(12):2821-7.

Cook DJ. Stress ulcer prophylaxis: gastrointestinal bleeding and nosocomial pneumonia. Best evidence synthesis. Scand J Gastroenterol Suppl. 1995;30(210):48-52.

Kristian Rorbaek Madsen, Kristian Lorentzen, Niels Clausen, Emilie Oberg, Peter Roy Casparij Kirkegaard, Nana Maymann-Holler and Morten Hylander Moller. Guideline for Stress Ulcer Prophylaxis in the Intensive Care Unit. Dan Med J 2014;61(3):C4811.

Downloads

Published

2018-04-21

Issue

Section

Case Reports