Delayed presentation of left-sided penetrating diaphragmatic injury with multivisceral herniation, gastric fundal perforation, and splenic laceration leading to fatal septic shock: a case report from Ethiopia

Abstract

Introduction and importance: Traumatic diaphragmatic injury following penetrating trauma is uncommon and easily overlooked; delayed diagnosis may lead to visceral herniation, perforation, contamination, and sepsis. Case presentation: A 21-year-old man presented 6 days after a posterior stab wound, referred from a primary hospital where a chest tube had been inserted for suspected hemopneumothorax. He was hypotensive, febrile, and hypoxic, with reduced left air entry, bowel sounds in the chest, and gastrointestinal contents draining through the tube. A chest radiograph showed a large left intrathoracic air-fluid level with mediastinal shift. Emergency laparotomy revealed a 12 cm left posterior diaphragmatic defect; herniation of the stomach, jejunum, transverse colon, and spleen; two gastric fundal perforations; and a grade I splenic laceration. The viscera were reduced; the gastric perforations were repaired in two layers with omental reinforcement; the diaphragm was closed primarily; and lavage was performed. Re-look laparotomy on postoperative day 2 confirmed intact repairs and drained a left subphrenic collection. Despite norepinephrine support and escalation from ceftriaxone/metronidazole to vancomycin/meropenem, he died on postoperative day 11 from refractory septic shock and multiorgan failure. Clinical discussion: This case highlights diagnostic pitfalls of delayed penetrating diaphragmatic injury, the significance of enteric chest-tube drainage, and the impact of referral delay and limited CT availability. Conclusion: Early suspicion, rapid transfer, and prompt operative source control are essential after thoracoabdominal stab wounds with suspected diaphragmatic injury.