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Acquired Diaphragmatic Hernias Workup

  • Author: Anne T Saladyga, MD; Chief Editor: Jeffrey C Milliken, MD  more...
 
Updated: Dec 05, 2014
 

Imaging Studies

Chest radiography

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 radiography, with an additional 25% found with subsequent films.[10] Chest radiography is most sensitive for detecting left-side 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") [10]
  • Nasogastric tube seen in the thorax (see the image below)
  • Elevated hemidiaphragm (>4 cm higher on the left than on the right)
  • Distortion of diaphragmatic margin
    Preoperative chest radiograph in a 53-year-old wom 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.

Computed tomography

Conventional computed tomography (CT) has been reported to have a sensitivity of 14-82%, with a specificity of 87%.[11] Helical CT has increased sensitivity, 71-100%, with higher sensitivity on the left than on the right.[10] CT findings indicative of rupture include the following:

  • Direct visualization of injury
  • Segmental diaphragm nonvisualization
  • Intrathoracic herniation of viscera
  • "Collar sign"
  • Peridiaphragmatic active contrast extravasation

Ultrasonography

Ultrasonography (focused assessment with sonography for trauma [FAST]) has been reported to detect diaphragmatic hernias.[12] 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]

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Diagnostic Procedures

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

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Laboratory Studies

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

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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.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel S Schwartz, MD, FACS Medical Director of Thoracic Oncology, St Catherine of Siena Medical Center, Catholic Health Services

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

Disclosure: Nothing to disclose.

Chief 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, 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, SWOG, Western Surgical Association

Disclosure: Nothing to disclose.

Acknowledgements

Jason M Johnson, DO Resident Physician, Department of General Surgery, Spartanburg Regional 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.

References
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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.
 
 
 
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