Colon in the Chest: An Incidental Dextrocardia

Diaphragmatic injury is an uncommon traumatic injury (<1%). Although most diaphragmatic injuries can be obvious (eg, herniation of abdominal contents on chest radiograph), some injuries may be subtle and imaging studies can be nondiagnostic in many situations. Patients with diaphragmatic hernia either traumatic or nontraumatic may initially have no symptoms or signs to suggest an injury to the diaphragm. Here, we report a case of a 75-year-old woman diagnosed with irritable bowel syndrome –associated dominant constipation, presented with shortness of breath, cough, expectoration, tachycardia, and chest pain. Dextrocardia was an incidental finding, diagnosed by electrocardiography, chest radiograph, and CT chest. Parts of the colon, small intestine, and stomach were within the thorax in the left side due to left diaphragmatic hernia of a nontraumatic cause. Acquired incidental dextrocardia was the main problem due to displacement of the heart to contralateral side by the GI (gastrointestinal) viscera (left diaphragmatic hernia). The patient was prepared for the laparoscopic surgical repair, using a polyethylene mesh 20 cm to close the defect, and the patient recovered with accepted general condition. However, 5 days postoperative, the patient passed away suddenly due to unexplained cardiac arrest. Intrathoracic herniation of abdominal viscera should be considered in patients presented with sudden chest pain concomitant with a history of increased intra-abdominal pressure. (Medicine 94(6):e507) Abbreviations: ATLS = advanced trauma life support, GI = gastrointestinal, GIT = gastrointestinal tract. ehab, MD, PhD, A , MD, PhD, hazly Baghdady, MD, PhD The incidence of dextrocardia has been reported to be less than 1% and a recent study found the incidence to be only 0.22%. Diaphragmatic hernia may lead to acquired dextrocardia. Recognition of the condition enables selecting the proper correctable measures. Patients with diaphragmatic hernia have variant symptoms and signs related to both gastroenterology and cardiology. The abnormalities of diaphragmatic hernia may be life threatening, and usually lead to serious complication. A high index of suspicion needs to be maintained because delayed diagnosis is associated with an increased risk of GI (gastrointestinal) strangulation, which can lead to morbidities and mortalities. Laparoscopy has a sensitivity of 88% and a specificity approaching 100% in the diagnosis of diaphragmatic injury. When identified, injury of the diaphragm is repaired with either open surgical or minimally invasive techniques. The method of choice and the timing of procedure depend on the presence of associated injuries, other medical disorders, and the overall condition of the patient. We present here a case of incidental dextrocardia due to left diaphragmatic hernia where huge parts of the GIT (gastrointestinal tract) were found within the thoracic cavity. CASE REPORT We have experienced a controlled diabetic Egyptian female patient, 75 years old, on insulin therapy, not hypertensive, with history of right knee arthroplasty. She has worked for a long time in an industrial factory; one of her duties was to carry heavy manufactured bags. That patient complained about abrupt abdominal pain, after carrying a heavy bag, 5 years ago. However, she did not seek any medical advice at that time. A year later, she retired and had a continuous complaint of intermittent, progressive attacks of dyspnea, abdominal pain, and constipation. The patient was diagnosed with IBS-dominant constipation. However, family history, past history, conventional abdominal U/S, and other investigations were irrelevant. With time progression, the condition worsened in the form of no passage of stool for successive 3 to 5 days, nausea, repeated vomiting, colicky abdominal pain, moderate form dyspnea, tachycardia, and chest pain. She was referred to specialized center for diagnosis and further management; intestinal obstruction was the primary differential diagnosis. Routine primary investigation revealed left diaphragmatic herniation, with parts of stomach, small and large intestines within the thorax, discontinuity of left diaphragmatic cruses, and the herniated viscera displaced the heart and other mediastinum structures to the contralateral side with shifted trachea to the right side (Figures 1 and 2). Echocardiography revealed dextrocardia with diastolic dysfunction; no masses or thrombi or other abnormalities could be detected. S AND EXPLANATION was carried out in Egypt. The Ethical Asiut faculty of Medicine, approved the www.md-journal.com | 1