Diaphragmatic Hernias Workup

  • Author: Nicola Lewis, MBBS, FRCS (Paed Surg); Chief Editor: Marleta Reynolds, MD   more...
 
Updated: Aug 1, 2011
 

Laboratory Studies

Antenatal

  • Amniocentesis for karyotype analysis should accompany a diagnosis of congenital diaphragmatic hernia (CDH).
  • Maternal serum alpha-fetoprotein may be low in cases of congenital diaphragmatic hernia.

Postnatal

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Imaging Studies

Llevel III ultrasonography and echocardiography should accompany a diagnosis of congenital diaphragmatic hernia. Prenatal echocardiography may identify cardiac anomalies (more commonly, ventricular hypoplasia, atrial septal defects, and ventricular septal defects).[13] In centers where fetal intervention and postnatal management protocols are determined by antenatal assessment of pulmonary hypoplasia, lung to head ratios (LHR) and lung-to-thorax transverse ratio (L/T) are calculated. One definition of the LHR is the area of the contralateral lung (the product of the 2 longest perpendiculars)/head circumference at the 4 chamber view. L/T is the ratio of the area of the contralateral lung/area of thorax at the 4 chamber view on ultrasonography.[14]

Chest radiography

An early chest radiograph is obtained to confirm the diagnosis of congenital diaphragmatic hernia.

Findings include loops of bowel in the chest, mediastinal shift, paucity of bowel gas in the abdomen, and presence of the tip of a nasogastric tube in the thoracic stomach (see image below). Repeated chest radiography may reveal a change in the intrathoracic gas pattern.

Radiograph of an infant with congenital diaphragmaRadiograph of an infant with congenital diaphragmatic hernia. Note shift of the mediastinum to the right, air-filled bowel in the left chest, and the position of the orogastric tube.

Right-sided lesions are difficult to differentiate from diaphragmatic eventration and lobar consolidation.

Echocardiography

Further investigations should include early echocardiography, which may reveal cardiac defects, decreased left ventricular mass, poor ventricular contractility, pulmonary and tricuspid valve regurgitation, and right-to-left shunting.

Repeated echocardiography is recommended to measure changes in the pulmonary artery pressure, left-to-right shunt, and flow across the ductus arteriosus.

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Contributor Information and Disclosures
Author

Nicola Lewis, MBBS, FRCS (Paed Surg),  Department of Surgery, Birmingham Children's Hospital, UK

Nicola Lewis, MBBS, FRCS (Paed Surg), is a member of the following medical societies: British Association of Paediatric Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Philip Glick, MD, MBA  Professor, Departments of Surgery, Pediatrics, and Gynecology and Obstetrics, Vice-Chairperson for Finance and Development, Department of Surgery, State University of New York at Buffalo

Philip Glick, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, Central Surgical Association, Federation of American Societies for Experimental Biology, Medical Society of the State of New York, Phi Beta Kappa, Physicians for Social Responsibility, Royal College of Surgeons of England, Sigma Xi, Society for Pediatric Research, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, and Society of University Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert K Minkes, MD, PhD  Professor of Surgery, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Medical Director and Chief of Surgical Services, Children's Medical Center of Dallas-Legacy Campus

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Andre Hebra, MD  Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

H Biemann Othersen Jr, MD  Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina

H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Marleta Reynolds, MD  Professor of Surgery, Northwestern University, The Feinberg School of Medicine; Head, Department of Surgery and Surgeon in Chief, Head, Division of Pediatric Surgery, Children's Memorial Hospital of Chicago

Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association

Disclosure: Nothing to disclose.

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Graph illustrating the concept of the hidden mortality of congenital diaphragmatic hernia. Image courtesy of Michael Harrison, MD.
Photograph of a one-day-old infant with congenital diaphragmatic hernia. Note the scaphoid abdomen. This occurs if significant visceral herniation into the chest is present.
Radiograph of an infant with congenital diaphragmatic hernia. Note shift of the mediastinum to the right, air-filled bowel in the left chest, and the position of the orogastric tube.
Newborn baby with congenital diaphragmatic hernia on venoarterial extracorporeal membrane oxygenation (ECMO). Note the arterial and venous cannulas connected to the bedside cardiovascular bypass machine.
Diagram illustrating the sheep model of PLUG, the trachea used for the fetal management of congenital diaphragmatic hernia. Image courtesy of Michael Harrison, MD.
 
 
 
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