Case presentation A 92-year-old man was referred to the emergency department by his general practitioner because of suspicion of pneumonia. The patient reported increasing dyspnoea and bilateral pain at the thoracic base. Four weeks earlier he fell from the stairs and since then he suffered TPCA-1 concentration from mid-dorsal back pain. Physical examination

of the lungs revealed tachypnoea, decreased breath sounds on the left side and unequal chest rise. Heart auscultation demonstrated regular rate tachycardia (110 bpm). The jugular venous pressure was raised. Abdominal examination showed a distended abdomen with hypoperistalsis, but no tenderness. On a chest x-ray a left tension pneumothorax was seen with pleural effusion on the left side and three recent basal dorsolateral rib fractures. Surprisingly a pneumoperitoneum was also visible on the chest x-ray (Figure 1). Needle decompression was immediately executed. Subsequently an apical chest tube was inserted on the left side and approximately 500 ml of serous and bloody fluid was drained. A computed tomography was made in search of the origin of intra-abdominal air. A

left posterolateral diaphragmatic rupture was found. In respect to the patient’s BTK activity age a conservative approach was chosen. He was admitted to the intensive care unit and a second basal chest tube was inserted on the left side and broad spectrum antibiotics were administered. The chest tubes were kept on suction (-10 cm H2O) to accelerate the rate of healing. On the seventh day brown liquid was observed from the basal chest tube. A new computed tomography was performed and this showed herniation of the transverse colon through Tau-protein kinase the hernia MRT67307 manufacturer defect in the left diaphragm (Figure 2). The basal chest tube had perforated the colon, thus creating a left fecopneumothorax. A laparoscopic repair was planned. During this procedure the herniated and perforated part of the colon was removed, a transdiaphragmatic lavage was undertaken and the omentum was used to close the diaphragmatic defect (Figures 3 and 4). A mesh or sutures were not used since the abdomen was contaminated with

feces. The 92-year-old-patient deceased on the fourth post-operative day due to respiratory insufficiency. Both the patient and family were in consent for abstinence from further invasive therapy. Figure 1 I nitial chest x-ray showing a left tension pneumothorax with shift of the mediastinum to the right, pleural effusion left, basal dorsolateral rib fractures. There’s also air visible under the right diaphragm (arrow). Figure 2 Computed tomography on the seventh day showing intrathoracic presence of bowel (colon transversum) with feces (arrow) and a basal chest tube. Figure 3 Peroperative picture: left posterior diaphragmatic rupture. Figure 4 Peroperative picture: colon transversum disappearing trough the diaphragmatic defect.