title: Incarcerated spontaneous transdiaphragmatic intercostal hernia.
abstract: BACKGROUND
  Prolapse of abdominal viscera into the thoracic subcutis through the chest wall is known as transdiaphragmatic intercostal hernia (TIH). Herein, we present the first case of spontaneous TIH presenting as a thoracoabdominal emergency.
  
  
  METHODS
  A 78-year-old male presented with acute left thoracoabdominal pain following a sudden bulge at the left posterolateral chest wall corresponding to a partially reducible soft tissue mass with ecchymosis at the overlying skin. Paroxysmal cough during the last four days was also reported along with a prolonged daily application of a special tight abdominal belt that used while milking sheep. CT-scan of the abdomen showed intrathoracic proptosis of the splenic flexure through a defect of the left hemidiaphragm and subcutaneous prolapse of the herniated colon through the 7th intercostal space. On laparotomy, the herniated colon showed signs of ischemic necrosis leading to segmental colectomy followed by repair of the diaphragmatic defect.
  
  
  CONCLUSIONS
  The clinical diagnosis of spontaneous TIH demands very high index of suspicion and thorough patient's history. In this case the daily elevation of the intraabdominal pressure due to an abdominal milking belt might have caused gradual slimming and loosening of the diaphragm and the intercostals muscles rendering them vulnerable to sudden increases of the thoracoabdominal pressure due to violent coughing. Such a hypothesis is reasonable in the absence of traumatic injury in this patient.
  
  
  CONCLUSIONS
  Spontaneous TIH should be suspected in patients presenting with a sudden palpable chest wall bulge and associated thoracoabdominal symptoms in the absence of preceding injury.
authors.affiliation: Department of General Surgery, University Hospital of Heraklion, Medical School of Heraklion, University of Crete, 71110 Heraklion, Crete, Greece.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Lasithiotakis
authors.forename: Maria
authors.initials: M
authors.lastname: Venianaki
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Tsavalas
authors.forename: George
authors.initials: G
authors.lastname: Zacharioudakis
authors.forename: Ioannis
authors.initials: I
authors.lastname: Petrakis
authors.forename: Maria
authors.initials: M
authors.lastname: Daskalogiannaki
authors.forename: George
authors.initials: G
authors.lastname: Chalkiadakis
references.citation: Eur Radiol. 2007 Jun;17(6):1411-21
references.pmid: 17308925
references.citation: Hernia. 2012 Feb;16(1):113-5
references.pmid: 20730461
references.citation: Radiol Clin North Am. 2006 Mar;44(2):199-211, vii
references.pmid: 16500203
references.citation: J Thorac Cardiovasc Surg. 2010 Jun;139(6):e127-8
references.pmid: 19660337
references.citation: Hernia. 2008 Oct;12(5):539-43
references.pmid: 18293055