A late complication from a self-inflicted stab wound.

Rupture of the diaphragm following penetrating injuries to the lower chest and upper abdomen is reported in as many as 10-15% of victims. The diagnosis may not be clinically apparent in the acute phase and routine investigations are often inadequate to identify any defect. Failure to detect the injury at the time ofpresentation may result in herniation of the abdominal contents into the chest cavity with significant associated morbidity and mortality. We report a case of large bowel obstruction presenting three years following the initial injury, and review the relevant literature. CASEREPORT A24-yearoldmanwas admitted as an emergency with a 48 hour history of increasing lower abdominal pain, distension, faeculent vomiting and absolute constipation. On examination he was dehydrated with signs of acute intestinal obstruction. Examination of all other systems was unremarkable. The patient suffered from chronic schizophrenia and three years previously had been treated for a self-inflicted stab wound to the anterior aspect of his left chest at the level of the costal margin. As a consequence of this injury he developed a left sided pneumothorax which was successfully treated with a chest tube and underwater seal drain. Other relevant history included a positive family history of colorectal carcinoma in two first-degree relatives. A plain abdominal film showed distended large bowel proximal to the splenic flexure consistent with an obstruction at this site (Fig 1). A left-sided pulmonary effusion was evident on chest x-ray (Fig 2). In an attempt to confirm the nature and site ofthe obstruction an urgent gastrograffin enema was performed (Fig 3). This demonstrated a complete obstruction at the level of the splenic flexure and subsequently he underwent a laparotomy. A segment of transverse colon had herniated through the diaphragm and become incarcerated within the thoracic cavity. The bowel was reduced and the defect repaired. His post-operative recovery was uncomplicated.