Diaphragmatic Rupture and Gastric Perforation in a Patient w
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A 54-year-old female patient was admitted to the emergency department complaining of fever and dry cough with symptoms of gastric reflux disease over the previous 5 days. She had a medical history of hypertension treated with an ACE inhibitor and a beta-blocker, and previous episodes of nephrolithiasis which always resolved with medical treatment. The patient did not have any harmful habits or chronic pulmonary disease.

At admission the patient had severe acute chest pain. Physical examination revealed an increased heart and respiratory rates of 110 beats/minute and 22 breaths/minute, respectively. The abdomen was painful, but soft with no palpable mass. An ECG showed a regular sinus rhythm with normal ventricular repolarization.

Blood arterial gas analysis revealed respiratory alkalosis and hypoxaemia, and a high A-a gradient suggesting an oxygen transfer/gas exchange problem. The patient was treated with high-flow oxygen, paracetamol and morphine sulfate for the management of severe pain, and intravenous fluid therapy with crystalloid solution. Point-of-care lung ultrasound showed diffuse bilateral B lines with irregular pleural thickening, and consolidation with air bronchogram and slight pleural effusion in the lower left lobe.

HRCT of the chest and abdominal CT scanning with contrast were performed and showed diaphragmatic rupture with gastric herniation and perforation, causing left pulmonary collapse with unilateral pleural effusion; the remaining pulmonary parenchyma of both lobes presented diffuse ground-glass opacities and multiple small consolidations, as reported in COVID-19 pneumonia. No rib fractures were detected.

To the best of knowledge, this is the first case of diaphragmatic rupture and gastric herniation in a patient with COVID-19 pneumonia to be reported the literature. The incidence of abdominal organ herniation due to diaphragmatic rupture is unknown since many cases likely go undiagnosed or are diagnosed late.

Source: https://www.ejcrim.com/index.php/EJCRIM/article/view/1738/2161
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