rupture of the congenital diaphragmatic eventration.

=Abstract=

Spontaneous Rupture of the Diaphragm in an 8 Years-old Girl with Nephrotic Syndrome

Seong-Cheol Lee, M.D., Ki-Hong Kim, M.D.

Department

0/

Surgery, Seoul National University College

0/

Medicine Seoul, Korea

Spontaneous rupture of the eventrated diaphragm is not common. The authors report a case of

spontaneous

rupture of the congenital diaphragmatic eventration.

An 8 year-old girl with right

congenital

diaphragmatic eventration and nephrotic syndrome was seen in emergency room because of

severe

abdominal pain and vomiting. She had intermittent abdominal pain for 1 year. Plain chest X-ray and ultrasonography showed entrapped bowels in the right thoracic area. Exploratory laparotomy revealed a ruptured right eventration. THE displaced abdominal viscera were repositioned into the abdominal cavity and the ruptured diaphragm was trimmed and plicated. The postoperative course was uneventful. Only one case of spontaneous rupture of eventrated diaphragmatic has been reported in the English literature

Index Words:

Diaphraf.?matic eventration, Spontaneous rupture

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1. Symbas PN, Hatcher CR, Waldo W: Dia- phragmatic eventration in infancy and child- hood. Ann Thorac Surg 24:113-119, 1977 2. Bekassy S.M, Dave KS, Wooler GH, Ionescu

MI: 'Spontaneous' and traumatic rupture of the diaphragm. Ann Surg 177:320-324, 1973 3. Mitchell TE, Ridley PO, Forrester-Wood CP:

Spontaneous rupture of a congenital diaphrag- matic eventration. Eur 1 Cardiothorac Surg 8:281-282, 1994

4. Bisgard 10, Neb 0: Congenital eventration of the diaphragm. 1 Thorac Surg 16:484-491, 1947

5. Smith CD, Sade RM, Crawford FA, Othersen HB: Diaphragmatic paralysis and eventration in infants. 1 Thorac Cardiovasc Surg 91 :490- 497, 1986

6. Malone PS, Brain AI, Kiely EM, Spitz L:

- 63 -

Congenital diaphragmatic defects that present late. Arch Os Childhood 64: 1542-1544, 1989 7. Beck We: Etiologic significance of eventration

of the diaphragm. Arch Surg 60: 1154-1160, 1950

8. Graviss ER, Danis RK, Lewis JE: Peritoneo- graphy diagnosis of delayed onset right-sided diaphragmatic hernia. J Pediatr 97: 119-1122, 1980

9. Langer JC, Filler RM, Coles J, Edmonds JF:

Plication of the diaphragm for infants and young children with phrenic nerve palsy. J Pediatr Surg 23:749-751, 1988

10. Stolar CJH, Dillon PW: Congenital diaphrag- matic hernia and eventration, in O'Neill JA Jr, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG: Pediatric Surgery(ed 5), chapter 53. Mosby-Year Book, St. Louis, 1988, Pp819 -837

11. ~:i'Hl,

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13. Ribet M, Linder JL: Plication of the dia- phragm for unilateral eventration or paralysis.

Eur J Cardiothorac Surg 6:357-360, 1992