Case report
A 19-year-old student was admitted with a 36-h history of abdominal pain, vomiting and absolute constipation, beginning after a heavy meal. He had two previous similar lesser episodes also after having eaten heavily; both settled spontaneously within a few hours. He gave no history of trauma or other symptoms.
He was pale, ill-looking and dehydrated, with a pulse of 1 lO/min, blood pressure I50/100 nimHg and temperature 36.5 "C. The apex beat was palpable on the right side. There was no air entry into the left chest which was hyper-resonant. The abdomen was tense but not distended with tenderness and guarding mostly in the left hypochondrium. No bowel sounds were audible.
A chest X-ray showed collapse of the left lung and bowel shadows in thcleft thorax. Fiuid levels were vkible on the erect abdomen. Laboratory data included the following: H b 17.7 g/dl. WBC 1 8 4 x 109/1, urea 7.7 mmol/l, Na 138 mmol/l, K 4.7mmol/l, amylase 3300 u/l (N 70-300 u/l).
The abdomen was opened through a left paramedian incision which was later extended along the eighth rib. The diaphragm was divided up to the hiatus. There was bloodstained fluid in the peritoneal cavity and areas of fat necroses in the omentuni. A gap, 8 x 5cm, was visible in the posterolateral part of the left diaphragm through which a large part of the stomach. transverse and descending colon, jejunum and tail of pancreas had herniated into the left thorax. The colon was adherent to the openin and lateral chest wall. There was an organo-axial torsion o f t h e stomach and the tail of the pancreas was cyanotic. The bowel was viable. The herniated abdominal organs were reduced and the defect in the diaphragm closed with Marlex mesh. Due to difficulty in accommodating all abdominal contents, a splenectomy was performed.
Posto eratively, after some problems with re-inflation of the left kng, the patient progressed well, the serum amylase returning to normal (290 u/l) within 72 h.
Twenty days later he developed a high intestinal obstruction which at laparotomy was found to be due to adhesions between a loop of jejunum, anterior abdominal wall and under surface of the diaphragm (not to the Marlex) causing an acute kink in the bowel. These were divided and the postoperative course was uneventful.
Seven months later he is asymptomatic and his chest X-ray satisfactory.