LETTER TO THE EDITOR
|Year : 2016 | Volume
| Issue : 4 | Page : 207-208
Eventration of diaphragm with gastric perforation in a child: A rare presentation
Kartik Chandra Mandal1, Shibsankar Barman2, Samiran Biswas2, Rajarshi Kumar2, Madhumita Mukhopadhyay3, Biswanath Mukhopadhyay2
1 Department of Pediatric Surgery, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
2 Department of Pediatric Surgery, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India
3 Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
|Date of Web Publication||19-Jul-2016|
Kartik Chandra Mandal
69/9 R. N. Guha Road, Nager Bazar, DumDum, Kolkata - 700 074, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mandal KC, Barman S, Biswas S, Kumar R, Mukhopadhyay M, Mukhopadhyay B. Eventration of diaphragm with gastric perforation in a child: A rare presentation. J Indian Assoc Pediatr Surg 2016;21:207-8
|How to cite this URL:|
Mandal KC, Barman S, Biswas S, Kumar R, Mukhopadhyay M, Mukhopadhyay B. Eventration of diaphragm with gastric perforation in a child: A rare presentation. J Indian Assoc Pediatr Surg [serial online] 2016 [cited 2019 Nov 13];21:207-8. Available from: http://www.jiaps.com/text.asp?2016/21/4/207/186560
Elevation of hemi-diaphragm is commonly due to diaphragmatic paralysis either congenital or acquired in origin. Congenital ED is indistinguishable from diaphragmatic hernia with sac. Larger the defect more the patient is symptomatic. Repeated nonbilious vomiting with upper abdominal fullness and respiratory distress should be investigated properly to diagnose gastric volvulus. Perforation and peritonitis in children with a past history of repeated nonbilious vomiting and respiratory distress the diagnosis of eventration with perforation of the gastrointestinal tract should be kept in mind. Early diagnosis and timely intervention give a good result.
A 2-year-old male child presented with rapidly increasing abdominal distension and respiratory distress with a past history of repeated nonbilious vomiting and upper abdominal distension. On examination, the patient was hemodynamically unstable with features of peritonitis. On admission, X-ray chest and abdomen showed distended stomach with mediastinal shifting to the right. Left hemi-diaphragm was elevated [Figure 1]a. So, diagnosis of eventration of the diaphragm and gastric volvulus was suspected. During preparation for operation abdominal distension was further increased. On exploration, free gas came out, and there was hemorrhagic collection inside the abdomen. Central major part of left hemi-diaphragm was thinned and elevated. There was a perforation in the posterior wall of stomach ~1 cm in diameter [Figure 1]b. Another male child of 1-year age presented with the similar presentation. After exploration gastric perforation was found at the anterior wall near greater curvature along with left sided ED.
|Figure 1: (a) Straight X-ray chest and abdomen showed distended stomach with mediastinal shifting to the right. Left hemi-diaphragm was elevated, (b) intraoperative picture showing posterior wall perforation (marked with Adson forcep)|
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Biopsy from perforation site taken and stomach perforation repaired with 4-0 vicryl in two layers. Central thinned part of diaphragm excised and repaired with 4-0 polypropylene in two layers. Postoperative feeding started on 3 rd day and patient was discharged on 5 th day with an uneventful recovery.
Eventration of the diaphragm is more common on the left side. Usually, present with respiratory tract infection and respiratory distress. Complicated ED may be presented with acute gastric volvulus featuring repeated vomiting and upper abdominal distension. A perforation in gastric volvulus is rare and few are reported.  Diagnosis of eventration was made by doing straight X-ray chest, computed tomography scan thorax and fluoroscopy. In emergency situation, straight X-ray abdomen and chest anteroposterior view are sufficient for confirmation. Elevated diaphragm, mediastinal shift, and large gastric air fluid level are suggestive of eventration with gastric volvulus. In our case, the child presented with a distended abdomen and respiratory distress. On investigation, there was a mediastinal shift with elevated left hemi-diaphragm and large gastric air fluid level no free gas under the diaphragm. In our patient, there was no free gas under the diaphragm in X-ray abdomen. Most probably, perforation took place in the time interval of admission (when the X-ray was taken) and the time of operation.
ED usually repaired through thoracic route. ED associated with gastric volvulus or suspected perforation need laparotomy. Here, we have explored through left upper abdominal transverse incision. Gastric volvulus, posterior wall of stomach perforation and left sided ED was detected and repaired without any drain.
Children with gastric outlet obstruction should be investigated keeping in mind that it may be due to eventration with gastric volvulus.
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Conflicts of interest
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| References|| |
Gupta V, Gupta P, Chandra A. Diaphragmatic eventration complicated by gastric volvulus with perforation. S Afr J Surg 2012;50:90-1.