Diaphragmatic Hernias, Acquired Workup

  • Author: Anne T Saladyga, MD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Jun 2, 2010
 

Laboratory Studies

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

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.[9] 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")[9]
    • Nasogastric tube seen in the thorax (see image below)Preoperative chest radiograph in a 53-year-old womPreoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident. Note the bowel contents in the left hemithorax. Nasogastric tube can be 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.[9] 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.[10] 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]
Previous
Next

Diagnostic Procedures

In stable patients in whom an isolated diaphragmatic tear is suspected, diagnostic laparoscopy or video-assisted thoracoscopic surgery (VATS) is indicated.

Previous
Proceed to Treatment & Management
 
 
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.

Specialty Editor Board

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, Southwest Oncology Group, and Western Surgical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Daniel S Schwartz, MD, FACS  Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital

Daniel S Schwartz, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, and Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

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  Professor and Chief, Cardiothoracic Surgery, Department of Surgery, Louisiana State University Health Sciences Center-Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

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. Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. Mar 2008;85(3):1044-1048. [Medline].

  3. Turhan K, Makay O, Cakan A, Samancilar O, Firat O, Icoz G, et al. Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac Surg. Jun 2008;33(6):1082-5. [Medline].

  4. Cameron JL. Diaphragmatic injury. In: Current Surgical Therapy. 9th ed. Philadelphia, PA: Mosby-Elsevier; 2008:975-987.

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

  6. 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].

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

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

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

  10. 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].

  11. 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].

  12. Düzgün AP, Ozmen MM, Saylam B, Coşkun F. Factors influencing mortality in traumatic ruptures of diaphragm. Ulus Travma Acil Cerrahi Derg. Apr 2008;14(2):132-8. [Medline].

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

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

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

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

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

  18. 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].

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

 
Previous
Next
 
Preoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident. Note the bowel contents in the left hemithorax. Nasogastric tube can be seen in the thorax.
Postoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.