A Fall With Consequences
A 66-year-old man under the influence of alcohol complained of very severe pain on the left side of the chest and in the left upper quadrant of the abdomen, radiating to the back. In view of these symptoms and his known history of stenosis of a single coronary vessel and implantation of a stent, the emergency physician presented him to the chest-pain unit. The ECG and laboratory findings were consistent with an NSTEMI (myocardial infarction without T-wave elevation; troponin I concentration 0.36 ng/mL, creatine kinase concentration 2553 U/L). Coronary angiography ruled out acute myocardial infarction and did not reveal any other pathological changes. The next day, the patient related that he had recently fallen on the left side of his chest. This piece of information, seen in the context of the laboratory findings, would have been a clue to the correct diagnosis if it had been known initially. Plain films and a computed tomographic scan of the chest revealed a left-sided diaphragmatic hernia of indeterminate age with an incarcerated intrathoracic stomach (Figure). This finding is said to be associated with acute diaphragmatic hernia after trauma in 1–5% of cases. The patient had an upside-down stomach that was already gangrenous because of strangulation. He underwent an emergency gastrectomy and esophagojejunostomy and was discharged from the hospital 7 days later.
Dr. med. Dani Id, Dr. med. Phillip Grotherr, Prof. Dr. med. Claus Schmitt, Klinik für Kardiologie, Angiologie und Intensivmedizin, Städtisches Klinikum Karlsruhe,
Conflict of interest statement: The authors state that they have no conflict of interest.
Cite this as: Id D, Grotherr P, Schmitt C: A fall with consequences. Dtsch Arztebl Int 2018; 115: 275. DOI: 10.3238/arztebl.2018.0275
Translated from the original German by Ethan Taub, M.D.