Posttraumatic diaphragmatic hernia and death--etiologic factor or putrefactive artifact?

Late-presenting diaphragmatic hernias, whether congenital or acquired, may remain clinically undetected until mediastinal shift with cardiorespiratory compromise or intestinal or gastric infarction with perforation occur. A right-sided diaphragmatic hernia with herniation of small intestine into the adjacent pleural cavity is described in a 72-year-old man who was found dead at home in a putrefactive state. Subsequently, a history of a motor vehicle accident 8 years previously was obtained. Although postmortem herniation due to extensive putrefactive change may have occurred, producing gaseous distention and migration of the intestine, tight twisting of the herniated intestine several times around a pleural fibrous adhesion suggested that the herniation could have been an antemortem event. Unfortunately, marked tissue autolysis prevented assessment of possible ischemic changes in the herniated intestine. Although diaphragmatic hernia may be a contributing factor to death at all ages, it may not be possible to exclude it as an artifact of putrefaction in a predisposed individual.