No evidences of midline shift were observed. The presence of a possible intracranial hematoma or a cranial bone fracture was ruled out. Notable oedema of the facial soft tissues, without however underlining fractures, was an additional finding. Approximately, six hours after the initial imaging evaluation, the persistence of patient’s symptoms i.e. vomiting as well as the migration of pain into the lower thorax dictated an additional workup. A second chest x-ray was obtained. (Figures 1. An elevated left hemi-diaphragm

with the stomach in the left chest was observed. Abdominal CT scan confirmed the presence of a left-sided diaphragmatic tear with herniation of abdominal context within the left hemi-thorax. (Figures 2. Figure 1 Plain chest x-ray with the stomach in the left hemi-diaphragm. Figure 2 Computed tomography scan image showing the herniation of the stomach RXDX-106 into the chest. The patient underwent emergency laparotomy via a midline incision where a near total herniation

of the stomach into the left hemithorax was observed. No resection was necessary as there were no ischemic changes or signs of perforation of the involved organ. The stomach was then successfully reduced into the abdomen revealing the hernia opening about 5 cm in length. (Figures 3. A primary repair with interrupted non-absorbable sutures was carried out without the use of a prosthetic mesh. (Figures 4. The relatively small size of the hernia opening was the main argument for this approach.

A chest tube was not necessary as pleura was not violated and a pneumothorax was not present. Operating SB525334 supplier time was 45 minutes. The patient had an uneventful postoperative period and was discharged on the fifth postoperative Dolutegravir day. Figure 3 An intraoperative photo showing the diaphragmatic defect after the reduction of the hernia contents. Figure 4 An intraoperative photo showing the final repair result. Discussion DR after blunt abdominal injury is a rare trauma condition. Correct diagnosis is often difficult and is usually established late raising significantly the associated mortality and morbidity. Single or serial plain chest radiographs with a high index of suspicion are diagnostic in many cases of DR [1, 4, 5]. However, missed cases result in herniation of the abdominal organs into the chest which finally enlarges the diaphragm defect. Chronic intermittent abdominal or chest pain, constipation, strangulation and perforation of the involved abdominal viscera are symptoms and consequences associated with the progressive herniation of the abdominal organs into the chest. As lung on the affected side is compressed, shortness of breath, dyspnea, and respiratory infections appear [3]. Tears of the diaphragm usually originate at the musculotendinous junction, mostly in the posterolateral aspect of the hemidiaphragms. The majority of these tears are on the left side.