eMedicine Specialties > Thoracic Surgery > Trauma

Diaphragmatic Hernias, Acquired: Workup

Author: Anne T Saladyga, MD, General Surgery Resident, Department of Surgery, William Beaumont Army Medical Center
Coauthor(s): Jason M Johnson, DO, General and Laparoscopic Surgeon, Department of General Surgery, William Beaumont Army Medical Center; Sidney R Steinberg, MD, FACS, Program Director, Department of General Surgery, Spartanburg Regional Healthcare System; Consulting Surgeon, Department of Surgery, WG Hefner Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Jan 14, 2008

Workup

Laboratory Studies

  • No laboratory studies are needed to confirm a traumatic rupture of the diaphragm.

Imaging Studies

  • Chest radiography is standard in the advanced trauma life support (ATLS) protocol for a trauma workup. Approximately 23-73% of traumatic diaphragmatic ruptures will be detected by initial chest radiograph, with an additional 25% found with subsequent films.2 Chest radiograph is most sensitive for detecting left-sided hernias. Chest radiographic findings that indicate traumatic rupture include the following:
    • Abdominal contents in the thorax, with or without signs of focal constriction ("collar sign")2
    • Nasogastric tube seen in the thorax
    • Elevated hemidiaphragm (>4 cm higher on left vs right)
    • Distortion of diaphragmatic margin
  • Conventional CT scan has been reported to have a sensitivity of 14-82%, with a specificity of 87%. Helical CT increased sensitivity 71-100%, with higher sensitivity left vs right.2 CT findings indicating rupture include the following:
    • Direct visualization of injury
    • Segmental diaphragm nonvisualization
    • Intrathoracic herniation of viscera
    • "Collar sign"
    • Peridiaphragmatic active contrast extravasation
  • Ultrasonography (focused assessment with sonography for trauma [FAST] scan) has been reported to detect diaphragmatic hernias.6 During visualization of each upper quadrant, the movement of the diaphragm was noted to be decreased in patients with diaphragmatic hernias. This technique is limited in patients who are on mechanical ventilation because of the positive pressure of the thoracic cavity.1

More on Diaphragmatic Hernias, Acquired

Overview: Diaphragmatic Hernias, Acquired
Workup: Diaphragmatic Hernias, Acquired
Treatment: Diaphragmatic Hernias, Acquired
Follow-up: Diaphragmatic Hernias, Acquired
Multimedia: Diaphragmatic Hernias, Acquired
References
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References

  1. Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med. Nov 2004;22(7):601-4. [Medline].

  2. Sliker CW. Imaging of diaphragm injuries. Radiol Clin North Am. Mar 2006;44(2):199-211, vii. [Medline].

  3. Hamoudi D, Bouderka MA, Benissa N, Harti A. Diaphragmatic rupture during labor. Int J Obstet Anesth. Oct 2004;13(4):284-6. [Medline].

  4. Hayden JD, Davies JB, Martin IG. Diaphragmatic rupture resulting from gastrointestinal barotrauma in a scuba diver. Br J Sports Med. Mar 1998;32(1):75-6. [Medline].

  5. West, John B. Normal Physiology; Acute Respiratory Failure. In: Anthony, Robert. Pulmonary Physiology and Pathophysiology. Baltimore, MD: Lippincott Williams & Wilkins; 2001:2-3; 129.

  6. Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med. Nov 2004;22(7):601-4. [Medline].

  7. Ahmed N, Whelan J, Brownlee J, Chari V, Chung R. The contribution of laparoscopy in evaluation of penetrating abdominal wounds. J Am Coll Surg. Aug 2005;201(2):213-6. [Medline].

  8. Cameron JL. Diaphragmatic injury. In: Current Surgical Therapy. 7th ed. Mosby-Year Book: St Louis, MO; 2001:1095-100.

  9. Fell SC. Surgical anatomy of the diaphragm and the phrenic nerve. Chest Surg Clin N Am. May 1998;8(2):281-94. [Medline].

  10. Irish MS, Holm BA, Glick PL. Congenital diaphragmatic hernia. A historical review. Clin Perinatol. Dec 1996;23(4):625-53. [Medline].

  11. Mandell GA, Finkelstein MS, Hallowell M. Delayed presentation of a symptomatic Morgagni hernia. South Med J. Oct 1989;82(10):1299-302. [Medline].

  12. Mansour KA. Trauma to the diaphragm. Chest Surg Clin N Am. May 1997;7(2):373-83. [Medline].

  13. Naunheim KS. Adult presentation of unusual diaphragmatic hernias. Chest Surg Clin N Am. May 1998;8(2):359-69. [Medline].

  14. Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg. Nov 1995;60(5):1444-9. [Medline].

  15. Sharma OP. Traumatic diaphragmatic rupture: not an uncommon entity--personal experience with collective review of the 1980's. J Trauma. May 1989;29(5):678-82. [Medline].

  16. van Vugt AB, Schoots FJ. Acute diaphragmatic rupture due to blunt trauma: a retrospective analysis. J Trauma. May 1989;29(5):683-6. [Medline].

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Further Reading

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Keywords

hiatal hernia, diaphragm, congenital diaphragmatic hernia, CDH, respiratory dysfunction, respiratory compromise, blunt trauma, penetrating trauma, diaphragmatic rupture, motor vehicle accident, gunshot wound, stab wound, diaphragmatic hernia, acquired hernia, acquired diaphragmatic hernia

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Contributor Information and Disclosures

Author

Anne T Saladyga, MD, General Surgery Resident, Department of Surgery, William Beaumont Army Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Jason M Johnson, DO, General and Laparoscopic Surgeon, Department of General Surgery, William Beaumont Army Medical Center
Disclosure: Nothing to disclose.

Sidney R Steinberg, MD, FACS, Program Director, Department of General Surgery, Spartanburg Regional Healthcare System; Consulting Surgeon, Department of Surgery, WG Hefner Veterans Affairs Medical Center
Sidney R Steinberg, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Surgical Education, South Carolina Medical Association, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine
Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, Southwestern Oncology Group, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Daniel S Schwartz, MD, FACS, Clinical Assistant Professor of Cardiothoracic Surgery, New York University School of Medicine; Consulting Staff, Department of Surgery, Division of Thoracic Surgery, North Shore University Hospital/Long Island Jewish Medical Center
Daniel S Schwartz, MD, FACS is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Diabetes Association, American Heart Association, American Medical Association, Association for Academic Surgery, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, Director of Cardiothoracic Transplantation, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

 
 
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