A 58 year old woman presented with a three week history of increasing epigastric pain and nausea. Her past medical history included a road traffic accident six years previously when she sustained fractures through the superior and inferior left pubic rami. Chest radiography showed a dilated gastric shadow with a fluid level (fig 1).

A barium swallow demonstrated a large paraoesophageal hernia with a gastric volvulus and hernial outlet obstruction (fig 2).

At operation the stomach had herniated through a defect in the left diaphragm.

The late presentation of a ruptured diaphragm is well recognised, and may occur up to 30 years after the original event.¹

However, in delayed presentation the significance of previous trauma may be overlooked when concentrating on the apparently recent symptoms.²

Other injuries are commonly associated with diaphragmatic rupture and pelvic fracture occurs in 15% to 25% of cases.²

Gastric volvulus is an abnormal rotation of the stomach. Most commonly the greater curve moves upwards to lie under the cupola of the left diaphragm.

For volvulus to occur the points of tethering must be stretched and weakened. This can occur in patients with connective tissue disorders (for example, Ehlers-Danlos syndrome) and in conditions where there is extra space into which the stomach can be pulled (for example, diaphragmatic hernia).

As gastric volvulus is itself rare,³ its coexistence with traumatic diaphragmatic hernia in this case made the diagnosis more difficult.

Diaphragmatic injury should always be considered in patients who have previously sustained trauma who subsequently present with unexplained abdominal pain.

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Figure 1

Chest radiograph taken at second presentation to accident and emergency.

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Figure 2

Barium swallow taken after second presentation to accident and emergency.