CT of blunt diaphragmatic rupture

Approach to Acute Traumatic and Nontraumatic Diaphragmatic Abnormalities

Acute diaphragmatic abnormalities encompass a broad variety of relatively uncommon and underdiagnosed pathologic conditions, which can be subdivided into nontraumatic and traumatic entities. Nontraumatic abnormalities range from congenital hernia to spontaneous rupture, endometriosis-related disease, infection, paralysis, eventration, and thoracoabdominal fistula. Traumatic abnormalities comprise both blunt and penetrating injuries. Given the role of the diaphragm as the primary inspiratory muscle and the boundary dividing the thoracic and abdominal cavities, compromise to its integrity can yield devastating consequences. Yet, diagnosis can prove challenging, as symptoms may be vague and findings subtle. Imaging plays an essential role in investigation. Radiography is commonly used in emergency evaluation of a patient with a suspected thoracoabdominal process and may reveal evidence of diaphragmatic compromise, such as abdominal contents herniated into the thoracic cavity. CT is often superior, in particular when evaluating a trauma patient, as it allows rapid and more detailed evaluation and localization of pathologic conditions. Additional modalities including US, MRI, and scintigraphy may be required, depending on the clinical context. Developing a strong understanding of the acute pathologic conditions affecting the diaphragm and their characteristic imaging findings aids in efficient and accurate diagnosis. Additionally, understanding the appearance of diaphragmatic anatomy at imaging helps in differentiating acute pathologic conditions from normal variations. Ultimately, this knowledge guides management, which depends on the underlying cause, location, and severity of the abnormality, as well as patient factors. ©RSNA, 2024 Supplemental material is available for this article.

The edemiological state of blunt diaphragmatic injury: An analysis of a nationwide trauma registry in Japan

BACKGROUND

Little is known about blunt traumatic diaphragmatic injury (BTDI). This study aimed to investigate the epidemiological state of BTDI, using a nationwide trauma registry in Japan.

METHODS

Data of patients aged ≥18 years who experienced blunt injury between January 2004 and May 2019 were extracted from the Japan Trauma Data Bank. Demographics, cause of trauma, mechanism of injury, physiological parameters, organ injuries, and bone fractures were compared between patients with and those without BTDI. Multivariable logistic regression analysis was performed to identify factors associated with BTDI.

RESULTS

A total of 305,141 patients from 244 hospitals were analyzed. The median patient age (interquartile range) was 65 (44-79) years, and 185,750 (60.9%) were men. BTDI was diagnosed in 868 patients (0.3%). The prevalence of BTDI was stable, between 0.2 and 0.6%, over the study period. Among the 868 patients with BTDI, 408 (47.0%) fatalities were recorded. Mortality rates in each year were 42.5-68.2%, with no significant trend toward an improved outcome (P = 0.925). Our multivariable logistic regression analysis found that mechanism of injury, Glasgow Coma Scale score (9-12 or 3-8) on hospital arrival, hypotension (systolic blood pressure <90 mmHg) on hospital arrival, organ injuries (lung, heart, spleen, bladder, kidney, pancreas, stomach, and liver), and bone fractures (rib, pelvis, lumbar spine, and upper extremities) were independently associated with BTDI.

CONCLUSION

Using a nationwide trauma registry, this study revealed the epidemiological state of BTDI in Japan. BTDI was found to be a very rare but devastating injury, with high in-hospital mortality. Some clinical factors, such as mechanism of injury, Glasgow Coma Scale score, organ injuries, and bone fractures, were independently associated with BTDI.

Laparoscopic Repair of Blunt Traumatic Diaphragmatic Hernia

Traumatic diaphragmatic hernias (TDHs) can occur after both blunt and penetrating injury. Laparotomy and thoracotomy are commonly done for the management of TDHs. Minimally invasive surgery, especially laparoscopic surgery, is being accepted as an effective and safe alternative to open surgical repair even in trauma cases. Laparoscopy also allows for the detection and management of clinically occult TDHs, thereby preventing the complications of missed or delayed diagnosis. Our case highlights the importance of timely intervention with a minimally invasive approach. A 39-year-old male presented to the emergency room after a road traffic accident. Computed tomography scan confirmed left-sided diaphragmatic rupture with gastric herniation. Laparoscopic repair of the hernia was done. He had an uneventful post-operative period. At the one-year follow-up, he was asymptomatic and was doing well. TDHs have a variable clinical presentation and radiological findings are not always diagnostic. Such cases can progress to potentially life-threatening complications such as strangulation and perforation of the herniated viscera. Timely diagnosis and management are therefore essential. A minimally invasive approach such as laparoscopy should be used for the management of TDHs in the acute setting where the patient is stable, and resources are available. In this case, once the gastric contents were aspirated via a nasogastric tube in the middle of the night, the immediate need for surgery was converted to an urgent nature, and the patient underwent surgery the next morning in a more controlled setting. In addition, timely intervention can prevent future complications that may occur if the condition is left untreated during the initial admission.

Laparoscopic repair and total gastrectomy for delayed traumatic diaphragmatic hernia complicated by intrathoracic gastric perforation with tension empyema: a case report

Background

Blunt traumatic diaphragmatic hernia (TDH) is a complication of blunt diaphragmatic injury. If missed, it could lead to critical presentations, such as incarceration or strangulation of the herniated intra-abdominal organs, and thus, early surgical repair is required. Methods of the operative approach against delayed TDH remain unclear. Even with the spread of the minimally invasive approach, laparotomy has been predominantly selected for cases with hemodynamic or gastrointestinal complaints. Literature on the use of laparoscopy for repair of such cases is limited, and no study has been conducted for those with intrathoracic gastric perforation.

Case presentation

A 55-year-old male patient with a history of multiple traumas presented with shock, followed by left hypochondrium pain and vomiting. The patient was admitted to the emergency department of our institution and diagnosed with delayed TDH complicated by intrathoracic gastric perforation, and tension empyema. Emergency surgery using laparoscopic approach was performed, despite unstable hemodynamics, considering orientation, exposure, and operativity compared with laparotomy. Repair of the diaphragm plus total gastrectomy was successfully performed by minimally invasive management. The patient made an uneventful recovery without recurrence after 8 months.

Conclusion

Unstable hemodynamic conditions and intrathoracic gastric perforation could not be contraindications to laparoscopic repair in treating delayed TDH.

Current trends in the diagnosis and management of traumatic diaphragmatic injuries: A systematic review and a diagnostic accuracy meta-analysis of blunt trauma

BACKGROUND

Traumatic diaphragmatic injuries (TDI) are wounds or ruptures of the diaphragm due to thoraco-abdominal trauma. Nowadays, CT-scan is considered the gold standard for TDI diagnosis. The aim of this study was to assess the current diagnostic accuracy of CT-scan in the diagnosis of TDI and describe the management of this type of injury.

METHODS

A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent reviewers searched the literature in a systematic fashion using online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the diagnosis and the following management of TDI were included. Pooled estimates of sensitivity, specificity, and positive/negative likelihood (with corresponding 95% confidence intervals) were analyzed based on the bivariate model for blunt TDI. The Newcastle-Ottawa scale for cohort studies was used for the quality assessment of selected articles. The PROSPERO registration number was as follows: CRD42022301282.

RESULTS

Fifteen studies published between 2001 and 2019 were included. All included studies reported a contrast-enhanced computed tomography as the preferred method to obtain diagnostic imaging. Left-sided TDI was the type of injury most frequently found. False negative TDI at CT-scan were more frequent than false positive TDI (11.13 ± 23.24 vs. 2.66 ± 6.65). Six studies on blunt TDI were included in the meta-analysis, showing a high sensitivity [0.80 (95%CI 0.65-0.90)] and specificity [0.98 (95%CI 0.89-1.00)] of the CT-scan in detecting TDI. Overall, 7 articles reported laparotomy as the method of choice to repair TDI. Only 3 studies reported a laparoscopic and/or thoracoscopic approach to TDI repair.

CONCLUSION

CT-scan has a good sensitivity and specificity for blunt TDI diagnosis. However, TDI diagnosis and management are often delayed. The use of water-soluble contrast in CT-scan should be considered when the diagnosis of TDI is not defined after the first scan, and clinical suspicion is still high. In this context, a highly trained trauma team is essential for trauma management and correct imaging interpretation.

Infiltrative invasion of the diaphragm: an uncommon manifestation of recurrent hepatocellular carcinoma A retrospective cohort study

Purpose: To report on infiltrative invasion of the diaphragm, an uncommon manifestation ofrecurrent hepatocellular carcinoma (HCC), and evaluate its clinical significance.Methods: Using the term “diaphragm” or “diaphragmatic” and “invasion” or “involvement,” we searched for patients in the database of radiologic reports of liver computed tomography or magnetic resonance imaging performed between 2012 and 2016 at our institution. Nine patients with infiltrative invasion of the diaphragm due to recurrent HCC were included. Their clinical and imaging findings were evaluated.Results: The median age of patients at the time of diagnosis was 68 years (range, 40 to 73). There were eight men and one woman. Imaging findings of infiltrative invasion of the diaphragm revealed diffuse thickening with enhancementinvolving a part ofthe diaphragm. The median interval between initial manifestation on imaging and radiologic diagnosis of infiltrative invasion ofthe diaphragm was 6.8 months (range, 3.4 to 18.6). In two of three patients who underwent surgicalresection, tumors of the diaphragm were controlled without recurrence. In six patients except for one patient who was not followed up, tumors recurred at the resection site or diaphragm tumors showed a partial response or disease progression.Conclusion: Infiltrative invasion of the diaphragm by recurrent HCC manifested with diffuse thickening and diaphragm enhancement on radiologic imaging. A good prognosis can be expected only in patients who are diagnosed early and undergo surgical resection.

An unusual presentation of acute diaphragmatic hernia complicated by tension gastrothorax an under-recognized cause of cardiac arrest due to a fall from a height: A case report and literature review

A diaphragmatic hernia is a protrusion of the abdominal contents into the negative pressure thoracic cavity through a congenital or acquired diaphragmatic defect. Generally, acquired diaphragmatic hernia is a rare, life-threatening condition that usually follows blunt/penetrating trauma or an iatrogenic cause, resulting in the diaphragmatic rupture, accompanied by the herniation of abdominal visceral organs. We report a 47-year-old male construction worker who sustained a fall from a height of about 30 feet height. He presented with hypoxia initially and, after a primary survey, was found to have a traumatic rupture of the diaphragm with herniation of the stomach and abdominal contents, causing signs of obstructive shock. After adequate resuscitation in the Emergency Department, he was rushed to operating room. There, he suffered two very short pulseless electrical activity cardiac arrests. Therefore, an emergency anterolateral thoracotomy was done, and it was extended into laparotomy to reduce the abdominal contents through the diaphragmatic tear of 12 cm, which restored the spontaneous circulation. He recovered eventually, despite chest infections and pulmonary atelectasis, and was discharged on the 28th day and remained in good condition during the outpatient visit. Tension gastrothorax or viscerothorax is rare, but an under-recognized cause of cardiac arrest in the trauma setting necessitates a vigilant evaluation and early suspicion to prevent a catastrophic outcome. This case report emphasizes the inclusion of tension viscero or abdominal thorax as one of the recognizable causes of a pulseless electrical activity cardiac arrest.

Need for a Change - Extended-FAST to Extended Diaphragmatic-FAST

Post-traumatic hypoxia can be due to different causes, namely airway problems, pneumothorax, hemothorax, lung contusion, flail chest, traumatic diaphragmatic injuries (TDI), aspiration due to low sensorium, a respiratory paradox in cervical spine injury, severe hypotension, etc., It is a great challenge to identify the cause of hypoxia in a trauma setting because the contributing factors can be multiple or can be a remote cause, which is often missed out. Here, we describe a 50-year-old female who presented to our emergency department with Post-traumatic hypoxia whose sensorium, blood pressure, chest X-ray, E-FAST computed tomography of brain, and other baseline investigation were completely normal, diagnosed later as TDI with the help of diaphragmatic ultrasound and computed tomography of thorax.

Non traumatic intrathoracic liver herniation mimicking a pulmonary metastasis in patient with breast cancer: A case report

Non-traumatic hepatic hernia is defined as hepatic protrusion through acquired or congenital defects on diaphragm without prior trauma. This event is rare among adults and infrequently reported in literature. 52-year-old Caucasian woman with surgically treated breast cancer with suspected lung metastasis detected during a routine Multidetector Computed Tomography lung exam. Ultrasound and subsequently Magnetic Resonance Imaging (MRI) was performed which revealed an overdiaphragmatic mass in contiguity with liver parenchyma compatible with overdiaphragmatic hepatic hernia. Differential diagnosis should be made with diaphragmatic or pulmonary nodule. Correct diagnosis can avoid further diagnostic investigations or invasive procedures such as biopsy. Magnetic Resonance Imaging is a non-risky method and can clarify interpretative doubts. Currently there are still controversies about traumatic or idiopathic nature of this hernia.

Repair of a delayed, traumatic dorsal diaphragmatic hernia using a single paracostal approach in a dog

CASE HISTORY

A 1-year-old German Shepherd dog presented for delayed onset of a traumatic, dorsal diaphragmatic hernia of the pars lumborum.

CLINICAL FINDINGS AND TREATMENT

Herniorrhaphy via a ventral midline celiotomy (with and without a paracostal extension) were unsuccessful and the hernia recurred. The hernia was successfully repaired using a single lateral paracostal surgical approach. This approach provided excellent exposure and should be considered for dorsal pars lumborum diaphragmatic hernia repairs.

DIAGNOSIS

Dorsal diaphragmatic hernia of the pars lumborum.

CLINICAL RELEVANCE

Whilst uncommon, tears to the dorsal aspect of the diaphragm should be considered as well as the more common radial or circumferential pars costalis tears. Pre-operative computed tomographic imaging can identify the exact location of the hernia in order to allow the best surgical approach to be determined. A lateral paracostal approach should be considered as an alternative to a ventral midline celiotomy with or without paracostal extension for repair of dorsal diaphragmatic hernias affecting the pars lumborum, as it provides excellent exposure. A single lateral paracostal approach has not been reported previously for diaphragmatic hernia repair in dogs.

Diagnostic accuracy of the trans-abdominal ultrasound in the assessment of dysfunctional hemidiaphragm due to non-pulmonic etiology

Background

To evaluate the role of the trans-abdominal ultrasound (TAUS) in the assessment of hemidiaphragmatic dysfunction—due to non-pulmonic causes—as compared to the conventional CT; 36 patients (22 males and 14 females; age range 5 to 84 years) were included in this study.

Results

In CT examination, the dysfunctional hemidiaphragm was considered when either a hernia/post-traumatic defects (present in 19.4% of patients, of which 5.5% were depicted on the right side and 13.8% were existing on the left side), or elevated copulae (present in 80.6% of patients, of which 58.8% were found on the right side (21 patients) and 22.2% were seen on the left side (8 patients).

The TAUS showed a high sensitivity, specificity, PPV, NPV, and over all accuracy {100% (95% CI = 59.04 to 100.00%), 100% (95% CI = 88.06 to 100.00%), 100%, 100%, 100% (95% CI = 90.26 to 100.00%), respectively} in detection of defects and hernias as compared to CT. A high sensitivity, specificity, PPV, NPV, and over all accuracy {96.55% (95% CI = 82.24 to 99.9%), 100% (95% CI=59.04 to 100.00%), 100%, 87.5% (95% CI = 50.50 to 97.96%), 97.22% (95% CI = 85.47 to 99.93%), respectively} were found in detection of thickness and motion abnormalities, and in the detection of subphrenic collections in cases with relevant elevated copula in CT.

Conclusion

Trans-abdominal ultrasound (TAUS) could accurately assess the diaphragmatic thickness and provides a real-time image of a dysfunctional hemidiaphragm due to a diaphragmatic and infradiaphragmatic causes as well as the diaphragmatic defects with high sensitivity and specificity in comparison to CT.

Diaphragmatic injury a hidden issue for divers following trauma: Case report

Occult diaphragmatic injury was uncovered in a patient who returned to scuba diving after a traumatic injury. Diaphragmatic injury can be a difficult diagnosis in the setting of trauma and a significant number of injuries are missed on the initial presentation. This has potential implications to those wishing to return to diving after trauma, and diving doctors must maintain a high degree of suspicion for such injuries.

Faecopneumothorax Caused by Perforated Diaphragmatic Hernia

Incarcerated diaphragmatic hernias with intrathoracic perforation of the colon is a very rare but serious surgical emergency. A 78-year-old male patient presented to our emergency department with severe abdominal pain. A computer tomography (CT) scan revealed herniation of the left transverse colon and spleen into the thorax with colon perforation and fecal contents in the thoracic cavity. An emergent laparotomy confirmed the radiological diagnosis and showed a 6 cm dehiscence of the left diaphragm with strangulation of the left transverse colon as well as the spleen. A left-sided hemicolectomy with terminal transversostomy and splenectomy were performed. The diaphragm was closed with interrupted nonabsorbable sutures. We abstained from reinforcement of the suture line with a mesh because of the feculent contamination of the abdominal cavity. After extensive thoracoscopic lavage and insertion of two chest tubes, the patient was transferred to the intensive care unit. Diaphragmatic hernia even after a mild chest trauma can cause fatal complications. Diagnosis and treatment can be challenging and an interdisciplinary approach is recommended. Due to the associated comorbidity and long-lasting sequelae, we believe the awareness of this rare pathology as a differential diagnosis is important; both as an abdominal and thoracic emergency.

Imaging evaluation of diaphragmatic injuries: Improving interpretation accuracy

Diaphragmatic Injuries (DIs) remain a challenging diagnosis with potential catastrophic delayed complications. A high degree of suspicion in every case of severe blunt thoracoabdominal trauma or penetrating thoracoabdominal injury is essential. This review will present the evidence and controversies on this topic providing a practical tutorial for radiologists hoping to improve their interpretive accuracy for both blunt and penetrating DIs. The imaging signs of diaphragmatic injuries will be explained with emphasis on multidetector CT. Diagnostic pitfalls, available protocols and other issues will be presented.

Unravelling the Mysteries of Traumatic Diaphragmatic Injury: An Up-to-Date Review

Traumatic diaphragmatic injury (TDI) is an underdiagnosed condition that has recently increased in prevalence due to its association with automobile collisions. The initial injury is often obscured by concurrent thoracic and abdominal injuries. Traumatic diaphragmatic injury itself is rarely lethal at initial presentation, however associated injuries and complications of untreated TDI such as herniation and strangulation of abdominal viscera have serious clinical consequences. There are 2 primary mechanisms of TDIs: penetrating TDI which tend to be smaller, more difficult to detect, and result in fewer complications; and blunt TDIs which are larger and have higher overall mortality due to associated injuries or delayed complications. The anatomy of thoracic and abdominal cavities distinguishes the epidemiology, pathophysiology, symptoms, treatment, and prognosis of right versus left TDI. Although there is no definitive radiologic sign for diagnosing TDI, many signs have been introduced in the literature and the concurrent presence of multiple signs increases the sensitivity of TDI detection. Conservative versus surgical management depends on mechanism of TDI, side, and most importantly the associated injuries.

Resolution of Chronic Shoulder Pain after Repair of a Posttraumatic Diaphragmatic Hernia: A 22-Year Delay in Diagnosis and Treatment

Diagnosing traumatic diaphragmatic rupture (TDR) due to penetrating rib fractures is challenging because the lesions are often too small to be detected and may present years after injury. Patients with delays in diagnosis of TDR rarely present with orthopaedic-related complaints of pain. We report the case of a 52-year-old female who presented with chronic left shoulder pain following a motor vehicle accident (MVA). In addition to left-side lower rib fractures, she also sustained a left-sided splenic laceration, pneumothorax, and two-part upper humerus fracture. Fracture treatment was percutaneous pinning; the other injuries were treated nonoperatively. Her shoulder pain could not be attributed to shoulder or neck pathology. Twenty years after the MVA, she began experiencing episodes of left-sided abdominal pain and nausea. A CT scan obtained two years later revealed a diaphragm hernia, which was repaired laparoscopically. Unique aspects of this case include (1) presentation to an orthopaedic surgeon with a chief complaint of chronic shoulder pain; (2) at 22 years, this is the fourth longest case of a delay in diagnosis of TDR; and (3) the unique symptom of ipsilateral referred shoulder pain, which immediately improved after hernia repair.

Acute and chronic traumatic diaphragmatic hernia: 10 years' experience

Controversy persists regarding many aspects of traumatic diaphragmatic hernia (TDH). We aimed to understand why some traumatic diaphragmatic injuries present with chronic hernia and to evaluate diagnosis and treatment options. Fifty acute and 19 chronic TDH patients were diagnosed and treated at our institution over a 10-year period. Clinical data from these two groups were analyzed statistically and compared. Chronic TDH patients had a significantly lower Injury Severity Score than acute TDH patients (10.26 ± 2.68 vs. 26.92 ± 4.79, P < 0.001). The most common surgical approach for acute and chronic TDH was thoracotomy and laparotomy, respectively. The length of the diaphragmatic rupture was significantly shorter in chronic TDH patients than acute TDH patients (6.00 ± 1.94 cm vs. 10.71 ± 3.30 cm, P < 0.001). The mean length of hospital stay was significantly longer for acute TDH patients than chronic TDH patients (41.18 ± 31.02 days vs. 16.65 ± 9.61 days, P = 0.002). In conclusion, milder trauma and a smaller diaphragmatic rupture were associated with delayed diagnosis. A thoraco-abdominal computed tomography scan is needed for patients with periphrenic injuries to avoid delayed diagnosis of TDH. Improved awareness and understanding of diaphragmatic injuries will increase the rate of early diagnosis and improve prognosis.

Chronic cough causing unexpected diaphragmatic hernia and chest wall rupture

Cough is a defense mechanism for airway protection and is associated with multiple systemic complications such as ribs fracture. Diaphragmatic rupture is commonly caused by blunt or penetrating trauma. We presented a case of a 72-year-old female with a 1-year history of chronic cough, not responding to medical management. Imaging showing abdominal herniation into the thoracic cavity and rib fracture due to diaphragmatic and chest wall rupture. Abdominal herniation and diaphragmatic rupture were repaired through surgery allowing resolution of symptoms. This is a life-threatening condition with a high-mortality rate in which early diagnosis and repair are desirable. Therefore, awareness of this uncommon complication of cough should be acknowledged.

Delayed traumatic diaphragmatic rupture: diagnosis and surgical treatment

Background

To investigate the diagnosis and surgical therapy of delayed diaphragmatic rupture.

Methods

Forty patients with traumatic diaphragmatic rupture with delayed presentation and diagnosis were collected in Peking Union Medical College Hospital from 2000 to 2018, and a retrospective analysis was performed.

Results

In all forty patients, 36 (90%) patients had a traumatic past history, and 32 (80%) patients had clinical manifestations when diagnosed. Left-sided diaphragmatic rupture was found in 32 (80%) patients and right in 8 (20%) patients. One patient received emergency surgery, and 39 received selective surgery. Thirty-eight patients received thoracotomy, and 2 patients received combined thoracic-abdominal surgery. Thirty-six patients received direct diaphragm suture, and 4 patients received mesh repair. One patient had an intestinal obstruction and received enterolysis 19 days after surgery. During follow-up, 1 patient experienced recurrence 2 years later.

Conclusions

Careful recording of past history and physical examination are the best approaches in diagnosing delayed presentation of traumatic diaphragmatic rupture. CT scan with reconstruction of the diaphragm is helpful in both diagnosis and differential diagnosis. Surgical therapy after diagnosis is the best treatment.

Diagnostic significance of diaphragmatic height index in traumatic diaphragmatic rupture

Purpose

Traumatic diaphragmatic rupture resulting from blunt trauma is usually severe. However, it is often overlooked during initial evaluation because there are no characteristic signs and symptoms. Thus, this study aimed to determine the clinical characteristics of diaphragmatic rupture caused by blunt trauma and investigate the diagnostic usefulness of diaphragmatic height index (DHI) measured using chest radiographs.

Methods

The cohort comprised patients who were admitted due to diaphragmatic rupture from blunt trauma. Patients were divided into 2 groups; the control group comprised patients with blunt trauma who were matched for age, sex, and Injury Severity Score, while the DHI group comprised patients with diaphragmatic rupture from blunt trauma. Receiver operating characteristic curve was used to determine the cutoff value of DHI for diaphragmatic injury. The sensitivity, specificity, predictability, accuracy, and likelihood ratio of the cutoff were then determined.

Results

A total of 60 patients were confirmed to have diaphragmatic rupture. The mean DHI in patients with diaphragmatic rupture on the right and left side were both significantly different compared to that in the control group. A DHI cutoff value of >1.31 showed 71% sensitivity and 87% specificity for diagnosing right diaphragmatic rupture, while a cutoff value of <0.43 showed 87% sensitivity and 76% specificity for diagnosing left diaphragmatic rupture.

Conclusion

DHI can be useful in the diagnosis of diaphragmatic rupture. DHI as determined using chest radiographs in patients with blunt abdominal trauma, particularly in those ineligible for diagnostic work-up, may help in the diagnosis of diaphragmatic rupture.

Innovative and Contemporary Interventions of Diaphragmatic Disorders

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

Surgical management of chronic diaphragmatic hernias

Chronic diaphragmatic hernia (CDH) is an uncommon disease which may be associated with significant morbidity and mortality. Antecedent (even many months or years before CDH development) blunt or penetrating thoracic/thoraco-abdominal trauma is generally recognized. A wide spectrum of different mechanisms of injury, timing in presentation, size of the diaphragmatic defect, types and amount of abdominal viscera herniated into the chest cavity, clinical symptoms are observed in CDHs. Thoracic and abdominal CT scan (with coronal, axial and sagittal reconstructions) is the best diagnostic tool; sometimes thoracic MRI is needed to better define the extent of the diaphragmatic defect and the number of abdominal organs displaced into the chest cavity. Surgery (sometimes urgent) represents the treatment of choice for CDH; diaphragmatic hernia direct repair with a tension-free suture is generally attempted; in case of very large defects or when a tension-free suture is deemed unfeasible, the use of prosthesis is recommended. This review article will discuss about CDH aetiology, clinical presentation diagnosis and surgical treatment.

Diagnosis of diaphragm injuries using modern 256-slice CT scanners: too early to abandon operative exploration

Background

Missed injury of the diaphragm may result in hernia formation, enteric strangulation, and death. Compounding the problem, diaphragmatic injuries are rare and difficult to diagnose with standard imaging. As such, for patients with high suspicion of injury, operative exploration remains the gold standard for diagnosis. As no current data currently exist, we sought to perform a pragmatic evaluation of the diagnostic ability of 256-slice multidetector CT scanners for diagnosing diaphragmatic injuries after trauma.

Methods

A retrospective review of trauma patients from 2011 to 2018 was performed at an American College of Surgeons-verified level 1 trauma center to identify the diagnostic accuracy of CT scan for acute diaphragm injury. All patients undergoing abdominal operation were eligible for inclusion. Two separate levels of CT scan technology, 64-slice and 256-slice, were used during this time period. The prospective imaging reports were reviewed for the diagnosis of diaphragm injury and the results confirmed with the operative record. Injuries were graded using operative description per the American Association for the Surgery of Trauma guidelines.

Results

One thousand and sixty-eight patients underwent operation after preoperative CT scan. Acute diaphragm injury was identified intraoperatively in 14.7%. Most with diaphragmatic injury underwent 64-slice CT (134 of 157, 85.4%). Comparing patients receiving 64-slice or 256-slice CT scan, there was no difference in the side of injury (left side 57.5% vs. 69.6%, p=0.43) or median injury grade (3 (3, 3) vs. 3 (2, 3), p=0.65). Overall sensitivity, specificity, and diagnostic accuracy of the 256-slice CT were similar to the 64-slice CT (56.5% vs. 45.5%, 93.7% vs. 98.1%, and 89.0% vs. 90.2%).

Discussion

The new 256-slice multidetector CT scanner fails to sufficiently improve diagnostic accuracy over the previous technology. Patients with suspicion of diaphragm injury should undergo operative intervention.

Level of evidence

I, diagnostic test or criteria.

Complication of hemothorax after CT-guided percutaneous biopsy of herniated liver masquerading as a pulmonary mass

Hemothorax is a rare complication of percutaneous needle biopsy in the chest at a rate of 0.092%. Rarer yet is diaphragm injury with herniation of intra-abdominal organs. The patient was a 56-year-old female undergoing evaluation for primary lung cancer diagnosis requiring lung mass biopsy. The largest pulmonary nodule was biopsied, which abutted the right hemidiaphragm with the complication of hemothorax. Angiography demonstrated that the source of bleeding was not attributed to intercostal artery injury. Pathology revealed that benign hepatic tissue was sampled. Based on the pathology results, angiographic findings, and detailed review of cross-sectional imaging, the tissue is consistent with herniated liver through the right hemidiaphragm mistaken to be a pulmonary nodule.

Post-menopausal acquired diaphragmatic herniation in the context of endometriosis

INTRODUCTION

Acquired diaphragmatic hernias are most commonly associated with traumatic thoracic injury and rarely heal spontaneously. Conditions that promote peritoneal seeding, such as endometriosis, are associated with spontaneous acquired diaphragmatic hernia formation. Non-traumatic acquired diaphragmatic herniation has previously been described in the context of catamenial pneumothorax, however post-menopausal endometriotic diaphragmatic herniation has not been previously reported.

PRESENTATION OF CASE

A 57 year old post-menopausal female presented with a strangulated ischaemic loop of small bowel herniating through an acquired right sided endometriotic diaphragmatic hernia not previously visualised on imaging. Clamshell thoracolaparotomy was conducted and the necrotic section of small bowel was resected. The diaphragm was repaired and the patient recovered post-operatively without complications.

DISCUSSION

This patient had a complete intestinal malrotation presenting acutely with a small bowel obstruction and herniation through an acquired diaphragmatic rupture. This was possibly related to a diaphragmatic defect caused by endometriosis.

CONCLUSION

We presented a case of a post-menopausal acquired diaphragmatic herniation secondary to endometriosis; resulting in acute intestinal obstruction and bowel infarction. To our knowledge, such a case has not been previously reported in existing literature.

[Diaphragmatic hernia in elective thoracic surgery]

AIM

To clarify the indications for reconstructive surgery in patients with diaphragmatic hernia.

MATERIAL AND METHODS

Retrospective trial has included 36 patients with diaphragmatic hernia for the period 1963-2017. There were 23 (63.9%) women and 13 (36.1%) men. The majority of patients (83%) underwent surgery at able-bodied age (18-60 years). 27 (75%) patients had hernia of weak diaphragmatic zones, 9 (25%) - posttraumatic hernia. Diaphragm repair was performed with primary suture. In 2 cases of posttraumatic hernia mesh endoprosthesis was used.

RESULTS

All patients were discharged. Postoperative complications arose in 4 (11.1%) patients, including 2 cases of mesh endoprosthesis deployment. Long-term outcome was followed-up in 15 patients from 6 months to 17 years. Recurrent hernia was absent in all cases.

CONCLUSION

Primary suture is acceptable for diaphragmatic hernia repair. Alloplastic repair is indicated for large defect, when primary suture is impossible or risk of its failure is high.

Delayed manifestations of abdominal trauma: follow-up abdominopelvic CT in posttraumatic patients

PURPOSE

Our study aims to investigate the frequency and patterns of delayed manifestations of abdominal and pelvic injuries which may not be identified or which fail to manifest on the initial abdominopelvic CT in posttraumatic patients.

METHODS

For our institutional review board (IRB)-approved retrospective study, our hospital trauma registry was queried for patients with blunt multitrauma and Injury Severity Score (ISS) ≥ 16 between January 2010 and August 2016, yielding 3735 patients. A total of 203 patients received a follow-up abdominopelvic CT within six months from the initial scan and those with new findings on follow-up CT were identified. A retrospective blinded review of the initial CT examinations was performed by two experienced radiologists. The retrospective readings and original reports were compared to categorize the new abnormalities detected on follow-up CT scans. The categories included missed injuries, late presentations and sequelae of trauma, and complications of surgery, hospital admission, and invasive procedures. The patients' notes were reviewed for the clinical indications, time interval for repeat CT examination, and subsequent clinical management. The software used for statistical analysis of the extracted data was Microsoft Excel for Mac (version 15.33).

RESULTS

Out of 3735 patients, 203 patients received 232 follow-up abdominopelvic CTs. The average elapsed time between the initial CT and the follow-up CT was 15 ± 27 days. Evaluation for an abdominal fluid collection was the most common clinical indication, accounting for 40% of the total number (n = 243) of indications. Delayed manifestations and complications of trauma were present in 41 patients due to 47 abnormalities, most commonly related to solid organ injury, followed by abdominal collections and hematoma. Twenty-nine CT findings (62%) were only detectable on follow-up CT, while nine injuries (19%) were missed on initial CT. The findings on repeated CT warranted eight surgical and 15 interventional procedures.

CONCLUSION

A small percentage of traumatic injuries may be unidentified or fail to manifest on the initial CT, resulting in delayed manifestations of abdominopelvic trauma, which may lead to subsequent readmission, delayed management, and more severe medical complications.

The hourglass sign

The Hourglass sign is a useful imaging clue for diagnosing diaphragmatic ruptures with viscera herniation on multidetector CT, with a sensitivity ranging from 16% to 63% and a specificity around 98%-100%. This sign is also commonly found in the literature under the name "Collar sign," first described in 1995 by Worthy et al. It refers to the waistlike constriction of the herniated structure at the site of the diaphragmatic rupture.

The breadth of the diaphragm: updates in embryogenesis and role of imaging

The diaphragm is an unique skeletal muscle separating the thoracic and abdominal cavities with a primary function of enabling respiration. When abnormal, whether by congenital or acquired means, the consequences for patients can be severe. Abnormalities that affect the diaphragm are often first detected on chest radiographs as an alteration in position or shape. Cross-sectional imaging studies, primarily CT and occasionally MRI, can depict structural defects, intrinsic and adjacent pathology in greater detail. Fluoroscopy is the primary radiologic means of evaluating diaphragmatic motion, though MRI and ultrasound also are capable of this function. This review provides an update on diaphragm embryogenesis and discusses current imaging of various abnormalities, including the emerging role of three-dimensional printing in planning surgical repair of diaphragmatic derangements.

Core curriculum illustration: blunt traumatic diaphragmatic hernia

This is the 43rd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC.

Traumatic injuries of the diaphragm: overview of imaging findings and diagnosis

Injuries to the diaphragm muscle occur in penetrating and severe blunt trauma and can lead to delayed hernia formation. Computed tomography is the mainstay in the diagnosis of these injuries, which may be subtle at presentation. Imaging findings differ between blunt and penetrating trauma. Key features in blunt trauma include diaphragm fragment distraction and organ herniation because of increased intra-abdominal pressure. In penetrating trauma, herniation is uncommon, and the trajectory of the object is critical in making the diagnosis of diaphragm injury in these patients. Radiologists must keep a high index of suspicion for injury to the diaphragm in cases of trauma to the chest or abdomen.

Budd-Chiari syndrome due to right hepatic lobe herniation: CT image findings of two rare clinical conditions

Hepatic herniation is a rare clinical condition. Most commonly it is associated with congenital diaphragmatic herniation or acquired through blunt diaphragmatic trauma. We present a case of a right hepatic lobe incisional hernia in a 75-year-old female who underwent partial right-sided nephrectomy 52 years previously. Evidence of partial Budd-Chiari syndrome was seen on CT scan that was presumed to be as a result of traction of the herniated liver. As far as we are aware this is the first case of a right-sided hepatic hernia with evidence of partial Budd-Chiari syndrome. The patient was treated conservatively with anticoagulation and analgesia.

Does a Negative Emergency Celiotomy Exclude the Possibility of Significant Diaphragmatic Injury? A Case Report and Review of the Literature

Introduction

Diaphragmatic rupture (DR) is an uncommon, potentially serious complication following blunt or penetrating abdominal trauma. Even with a high index of suspicion, the diagnosis of DR can easily be missed for a long period post injury. Delayed or missed diagnosis [delayed diagnosis of diaphragmatic rupture (DDDR)] and delayed diaphragmatic rupture (DDR) are possible explanations in cases where the initial operative exploration fails to show the diaphragmatic damage.

Case Presentation

Here we present a patient with suspected DR that was not seen on initial open abdominal exploration, but was suggested by subsequent serial imaging. This injury was ultimately identified on laparoscopic exploration. The procedure was converted to open (celiotomy) due to poor tolerance of the pneumoperitoneum required for laparoscopy, and the laceration was primarily repaired. We propose that DDR and DDDR be considered as a differential diagnosis in patients with a previous thoraco-abdominal trauma when presenting with radiologic/clinical signs suspicious for DR, even when the immediate post traumatic exploration failed to demonstrate a DR.

Conclusions

A high index of suspicion is essential for early detection of DDR and DDDR. Patients with high impact injuries or surrounding organ damage should be followed with serial clinical examinations, follow-up radiologic assessments, and even re-exploration in situations highly suspicious for diaphragmatic injuries.

Traumatic diaphragmatic rupture with combined thoracoabdominal injuries: Difference between penetrating and blunt injuries

PURPOSE

Traumatic diaphragmatic rupture (TDR) needs early diagnosis and operation. However, the early diagnosis is usually difficult, especially in the patients without diaphragmatic hernia. The objective of this study was to explore the early diagnosis and treatment of TDR.

METHODS

Data of 256 patients with TDR treated in our department between 1994 and 2013 were analyzed retrospectively regarding to the diagnostic methods, percentage of preoperative judgment, incidence of diaphragmatic hernia, surgical procedures and outcome, etc. Two groups were set up according to the mechanism of injury (blunt or penetrating).

RESULTS

Of 256 patients with a mean age of 32.4 years (9-84), 218 were male. The average ISS was 26.9 (13-66); and shock rate was 62.9%. There were 104 blunt injuries and 152 penetrating injuries. Preoperatively diagnostic rate was 90.4% in blunt injuries and 80.3% in penetrating, respectively, P < 0.05. The incidence of diaphragmatic hernia was 94.2% in blunt and 15.1% in penetrating respectively, P < 0.005. Thoracotomy was performed in 62 cases, laparotomy in 153, thoracotomy plus laparotomy in 29, and combined thoraco-laparotomy in 12. Overall mortality rate was 12.5% with the average ISS of 41.8; and it was 21.2% in blunt injuries and 6.6% in penetrating, respectively, P < 0.005. The main causes of death were hemorrhage and sepsis.

CONCLUSIONS

Diagnosis of blunt TDR can be easily obtained by radiograph or helical CT scan signs of diaphragmatic hernia. For penetrating TDR without hernia, "offside sign" is helpful as initial assessment. CT scan with coronal/sagittal reconstruction is an accurate technique for diagnosis. All TDR require operation. Penetrating injury has a relatively better prognosis.

The Role of Computed Tomography in the Diagnostics of Diaphragmatic Injury After Blunt Thoraco-Abdominal Trauma

Background

Diaphragmatic injuries occur in 0.8–8% of patients with blunt trauma. The clinical diagnosis of diaphragmatic rupture is difficult and may be overshadowed by associated injuries.

Diaphragmatic rupture does not resolve spontaneously and may cause life-threatening complications.

The aim of this study was to present radiological findings in patients with diaphragmatic injury.

Material/Methods

The analysis of computed tomography examinations performed between 2007 and 2012 revealed 200 patients after blunt thoraco-abdominal trauma. Diaphragmatic rupture was diagnosed in 13 patients. Twelve of these patients had suffered traumatic injuries and underwent a surgical procedure that confirmed the rupture of the diaphragm. Most of diaphragmatic ruptures were left-sided (10) while only 2 of them were right-sided. In addition to those 12 patients there, another patient was admitted to the emergency department with left-sided abdominal and chest pain. That patient had undergone a blunt thoracoabdominal trauma 5 years earlier and complained of recurring pain. During surgery there was only partial relaxation of the diaphragm, without rupture.

The most important signs of the diaphragmatic rupture in computed tomography include: segmental discontinuity of the diaphragm with herniation through the rupture, dependent viscera sign, collar sign and other signs (sinus cut-off sign, hump sign, band sign).

Results

In our study blunt diaphragmatic rupture occurred in 6% of cases as confirmed intraoperatively.

In all patients, coronal and sagittal reformatted images showed herniation through the diaphragmatic rupture. In left-sided ruptures, herniation was accompanied by segmental discontinuity of the diaphragm and collar sign. In right-sided ruptures, predominance of hump sign and band sign was observed.

Other signs were less common.

Conclusions

The knowledge of the CT findings suggesting diaphragmatic rupture improves the detection of injuries in thoraco-abdominal trauma patients.

Blunt diaphragmatic lesions: Imaging findings and pitfalls

Blunt diaphragmatic lesions (BDL) are uncommon in trauma patients, but they should be promptly recognized as a delayed diagnosis increases morbidity and mortality. It is well known that BDL are often overlooked at initial imaging, mainly because of distracting injuries to other organs. Sonography may directly depict BDL only in a minor number of cases. Chest X-ray has low sensitivity in detecting BDL and lesions can be reliably suspected only in case of intra-thoracic herniation of abdominal viscera. Thanks to its wide availability, time-effectiveness and spatial resolution, multi-detector computed tomography (CT) is the imaging modality of choice for diagnosing BDL; several direct and indirect CT signs are associated with BDL. Given its high tissue contrast resolution, magnetic resonance imaging can accurately depict BDL, but its use in an emergency setting is limited because of longer acquisition times and need for patient’s collaboration.

Fractured Ribs and the CT Funky Fat Sign of Diaphragmatic Rupture

Traumatic diaphragmatic rupture remains a diagnostic challenge for both radiologists and surgeons. In recent years, multidetector CT has markedly improved the diagnosis of diaphragmatic injury in polytrauma patients. Herein, we describe two cases of subacute presentation of traumatic diaphragmatic rupture from a penetrating rib fracture and subsequent intrathoracic herniation of omental fat, representing the CT “funky fat” sign.

Tension pneumothorax due to perforated colon

A very rare case of traumatic diaphragmatic hernia is reported in a 65-year-old woman who presented 46 years after her initial thoracoabdominal injury with tension faecopneumothorax caused by a perforated colon in the chest cavity. She presented in a critical condition with severe respiratory distress, sepsis and acute kidney injury. She had a long-standing history of bronchial asthma with respiratory complications and had experienced progressive shortness of breath for the past year. A recent CT scan had excluded the presence of a diaphragmatic hernia but showed a significantly raised left hemidiaphragm. On admission, chest X-rays showed a significantly raised left hemidiaphragm and mediastinal shift, but the possibility of a diaphragmatic hernia with strangulated bowel in the chest was not suspected until the patient was reviewed by the surgical and intensive care unit consultants the next morning and a repeat CT performed. She had a successful outcome after her emergency operation.

Case-based discussion: an unusual manifestation of diaphragmatic hernia mimicking pneumothorax in an adult male

Diaphragmatic hernia is an important cause of emergency hospital admission associated with significant morbidity. It usually results from congenital defect or rupture in the diaphragm due to trauma. Prompt and appropriate diagnosis is necessary in patients with this condition, as surgical intervention by either abdominal or thoracic approach may be necessary. Here, we report a case of left-sided diaphragmatic hernia presenting with sudden onset of breathlessness, respiratory distress and left-sided chest pain radiating to the abdomen, mimicking pneumothorax, treated successfully with surgical intervention.