Traumatic Diaphragmatic Hernia Erin Chen Harvard Medical School, - - PowerPoint PPT Presentation

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Traumatic Diaphragmatic Hernia Erin Chen Harvard Medical School, - - PowerPoint PPT Presentation

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2/24/2012 Erin Chen 2012 Gillian Lieberman, MD Traumatic Diaphragmatic Hernia Erin Chen Harvard Medical School, Year 3 Gillian Lieberman, MD Erin Chen 2012 Gillian Lieberman, MD Presentation Agenda 1 Index Patient: Clinical

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Traumatic Diaphragmatic Hernia

Erin Chen Harvard Medical School, Year 3 Gillian Lieberman, MD

2/24/2012

Erin Chen 2012 Gillian Lieberman, MD

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Presentation Agenda

Erin Chen 2012 Gillian Lieberman, MD

1 Index Patient:

  • Clinical presentation
  • Imaging

2Introduction to diaphragmatic injuries

  • Anatomy
  • Classification
  • Facts

3Gallery of diaphragms

  • Anatomic variants
  • Diaphragmatic injuries on CXR and CT

4Summary of findings on CXR and CT

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Index Patient: Clinical presentation

  • Male presents after fall down 1 flight of stairs
  • Pulse ox 92% on arrival
  • PMH, PSH, MAH not contributory
  • SH: No tobacco, EtOH, drugs

Erin Chen 2012 Gillian Lieberman, MD

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Erin Chen 2012 Gillian Lieberman, MD

Index Patient: Initial CXR

  • lateral left 6th and 7th rib fx
  • linear atelectasis at bases
  • moderate pneumothorax

BIDMC PACS BIDMC PACS

CXR, frontal CXR with edge enhancement

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Index Patient: Hospital course

  • CXR diagnosed multiple rib fractures and a moderate

right pneumothorax

  • A chest tube was placed and the patient was observed
  • vernight
  • Serial CXR documented interval decrease in the

pneumothorax and the patient was deemed ready for discharge.

Erin Chen 2012 Gillian Lieberman, MD

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Erin Chen 2012 Gillian Lieberman, MD

Index Patient: Discharge CXR shows resolved pneumothorax

BIDMC PACS

  • small infiltrates at bases

CXR, frontal

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Erin Chen 2012 Gillian Lieberman, MD

Index Patient: Clinical presentation 10 days later

  • Persistent pain and shortness of breath since discharge
  • Denies abdominal pain or trouble with bowel movements
  • Gets CT with contrast to rule out effusion vs hemothorax
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Erin Chen 2012 Gillian Lieberman, MD

Index Patient: CT shows L pleural effusion

BIDMC PACS BIDMC PACS CT with contrast, lung window CT with contrast, lung window

  • large left pleural effusion

Axial CT slice at the carina Axial CT slice through the heart

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Erin Chen 2012 Gillian Lieberman, MD

Index Patient: CT shows diaphragmatic hernia

BIDMC PACS CT with contrast, soft tissue window BIDMC PACS

Axial CT slice through the heart Sagittal view

  • low attenuation fat herniating

through the L hemidiaphragm

  • left pleural effusion

* *

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Erin Chen 2012 Gillian Lieberman, MD

  • 5-9 rib fractures (only 6-7

shown here)

  • Slight mediastinal shift to right

due to left pleural effusion

  • No bowel in L hemithorax

Index Patient: CT shows mediastinal shift

BIDMC PACS CT with contrast, soft tissue window

Coronal view

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  • CT showed a small left diaphragmatic hernia. This caused herniation of
  • mental fat and a large pleural effusion, likely responsible for the patient’s

dyspnea.

  • The diaphragmatic tear probably resulted from his fall 10 days ago but

was missed on initial presentation.

  • The diaphragmatic defect was surgically repaired. Pathology report

showed incarcerated omentum.

  • Luckily, our patient had no incarcerated bowel in the hernia. This is a

major complication of diaphragmatic injuries. It is important to repair diaphragmatic tears before they cause bowel incarceration.

Index Patient: Clinical outcome

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Diaphragmatic injuries are missed in up to 60% of initial presentations! Let’s review the anatomy of the diaphragm in order to understand different diaphragmatic defects.

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Diaphragmatic anatomy: Where do injuries occur?

Erin Chen 2012 Gillian Lieberman, MD

  • Divides negative-pressure thoracic from

positive-pressure abdomen so there is always a pressure gradient across the diaphragm

  • The diaphragm consists of 3 muscle groups

and a central tendon

  • Gaps between muscle groups are only

pleura, peritoneum, and fascia and are weak

  • Hernias most often occur in these gaps, in

the central tendon, or in the tendon/muscle junction

Adapted from Sandstrom et al. Curr Prob Diagn Rad 2011.

central tendon

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Diaphragmatic defects: Classification

Erin Chen 2012 Gillian Lieberman, MD

Congenital

  • Bochdalek – posterior lateral defect (“Boch”dalek = “back”)
  • Morgagni – anterior medial defect (“M”orgagni = “M”edial)
  • eventration – focal muscular aplasia

Acquired

  • Hiatal – commonly associated with GERD
  • Traumatic – we will focus on traumatic injuries in the next slide
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Traumatic diaphragmatic injury: Facts

Erin Chen 2012 Gillian Lieberman, MD

  • Graded based on injury size and tissue loss BUT grading does not

correlate to morbidity or mortality

  • Injury occurs via penetration (65%) or blunt force (35%), which causes

a sudden increase in intra-abdominal pressure. An increase in pressure gradient across the diaphragm to 150-200 cmH2O can cause rupture

  • Diaphragmatic rupture occurs in 1-6% of major thoracic traumas
  • L hemidiaphragm 3x more likely to be injured than right with blunt

trauma, likely because the liver protects the right hemidiaphragm

  • Only 30-40% of patients get a pre-op diagnosis of diaphragmatic injury
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Gallery of diaphragms: How to recognize injury

Erin Chen 2012 Gillian Lieberman, MD

  • Examples of fake-outs
  • Examples of diaphragmatic injury on CXR
  • Examples of diaphragmatic injury on CT
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Certain anatomic variants can be mistaken for diaphragmatic injuries on imaging Let’s see some examples in the next two slides…

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Erin Chen 2012 Gillian Lieberman, MD

Companion patient #1: diaphragmatic slip

  • Normal anatomic variant
  • Echogenic by ulrasound, can

mimic intrahepatic mass

Sandstrom et al. Curr Prob Diagn Rad 2011.

  • Bundles of muscle on inferior

surface of diaphragm

CT abdomen, coronal view

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Erin Chen 2012 Gillian Lieberman, MD

Companion patient #2: diaphragmatic eventration

  • Focal muscular aplasia causing bulging of diaphragm
  • Rarely, may cause dyspnea, failure to thrive, recurrent pneumonia

Sandstrom et al. Curr Prob Diagn Rad 2011. Sandstrom et al. Curr Prob Diagn Rad 2011.

CXR, frontal CXR, lateral

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Gallery of diaphragms: How to recognize injury

Erin Chen 2012 Gillian Lieberman, MD

 Examples of fake-outs

  • Examples of diaphragmatic injury on CXR
  • Examples of diaphragmatic injury on CT
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Erin Chen 2012 Gillian Lieberman, MD Shanmuganathan et al. J Thor Imag 2000.

Companion patient #3: CXR showing the stomach in the thorax

  • Abdominal organs in the chest =

most obvious sign of diaphragmatic disruption

  • Here, the stomach bubble is in

the right hemithorax

  • A radio-opaque NG tube is seen

inside the stomach *

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Erin Chen 2012 Gillian Lieberman, MD

Companion patient #4: CXR showing the collar sign

  • “Collar sign” = constriction of the
  • rgan when it passes through a

narrow opening in the diaphragm

  • Here, the stomach is constricted

at the level of the diaphragm

  • Therefore, the stomach is passing

through the diaphragm, making this finding distinct from diaphragm elevation

Shanmuganathan et al. J Thor Imag 2000.

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Erin Chen 2012 Gillian Lieberman, MD

  • The left hemidiaphragm is seen

laterally but becomes indistinct medially

Sandstrom et al. Curr Prob Diagn Rad 2011.

Companion patient #5: CXR showing an indistinct hemidiaphragm

  • This is a very nonspecific sign

and can look similar to a pleural effusion or consolidation

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Erin Chen 2012 Gillian Lieberman, MD

  • Elevated right hemidiaphragm

suggests injury to the muscle and nerves

Sandstrom et al. Curr Prob Diagn Rad 2011.

Companion patient #6: CXR showing elevation of the right hemidiaphragm

  • Right pleural effusion versus

hemothorax

*

  • These are nonspecific signs that

may suggest diaphragmatic injury given a history of trauma. However, they may also be caused by infection or malignancy.

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Gallery of diaphragms: How to recognize injury

Erin Chen 2012 Gillian Lieberman, MD

 Examples of fake-outs  Examples of diaphragmatic injury on CXR

  • Examples of diaphragmatic injury on CT

As we have seen, CXR signs of diaphragmatic injury are

  • ften nonspecific. The next step in evaluation is CT…
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Erin Chen 2012 Gillian Lieberman, MD

Normal diaphragm on CT, axial view

http://www.bmb.leeds.ac.uk/teaching/visible/xray1012.gif

Liver

diaphragm

Spleen Colon Pancreas

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Erin Chen 2012 Gillian Lieberman, MD

  • Discontinuity in the left

hemidiaphragm with surrounding edema

  • Most sensitive sign on CT

(~70% sensitivity)

Shanmuganathan et al. J Thor Imag 2000.

Companion patient #7: CT showing diaphragm discontinuity

Axial CT slice through top of liver

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Erin Chen 2012 Gillian Lieberman, MD Sandstrom et al. Curr Prob Diagn Rad 2011.

Companion patient #8: CT showing diaphragm thickening

  • Right hemidiaphragm is

thickened

  • Compare to the normal left

hemidiaphragm

  • Thickening is caused by

muscular contraction, edema, and/or hematoma

CT abdomen, axial slice

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Erin Chen 2012 Gillian Lieberman, MD

  • The herniating liver has a narrow

waist where it passes through the smaller diaphragmatic defect

  • “Collar sign” is ~30-60% sensitive
  • n CT

Sandstrom et al. Curr Prob Diagn Rad 2011.

Companion patient #9: CT collar sign in the liver

CT abdomen, coronal view

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Erin Chen 2012 Gillian Lieberman, MD

Companion patient #10: CT collar sign in the stomach

Sandstrom et al. Curr Prob Diagn Rad 2011.

  • The stomach has herniated

through a small defect in the right hemidiaphragm

  • Refer to companion patient #4 for

a similar example of collar sign on CXR

CT chest, coronal view

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Erin Chen 2012 Gillian Lieberman, MD

  • The stomach directly contacts the

posterior rib without intervening lung

  • Findings can be more obvious in a

different reconstruction

stomach

Sandstrom et al. Curr Prob Diagn Rad 2011.

Companion patient #11: Dependent organ sign on CT

CT with contrast, axial view CT with contrast, coronal view

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Erin Chen 2012 Gillian Lieberman, MD

The examples we have seen so far show blunt diaphragmatic injuries. However, 65% of diaphragmatic injuries actually occur from penetrating trauma. Penetrating trauma usually causes a <2 cm defect, making them especially difficult to visualize. Let us examine an example of penetrating trauma on CXR and CT…

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Erin Chen 2012 Gillian Lieberman, MD

  • This patient’s CXR is normal

Sandstrom et al. Curr Prob Diagn Rad 2011.

Companion patient #12: Penetrating diaphragmatic trauma

  • However, his CT shows

diaphragmatic discontinuity.

Sandstrom et al. Curr Prob Diagn Rad 2011.

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Gallery of diaphragms: Summary

Erin Chen 2012 Gillian Lieberman, MD

 Examples of fake-outs  Examples of diaphragmatic injury on CXR  Examples of diaphragmatic injury on CT

  • We have now seen examples of diaphragmatic injuries

from both penetrating and blunt trauma on CXR and CT.

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Summary: CXR diagnosis of diaphragmatic injury

Erin Chen 2012 Gillian Lieberman, MD

  • Findings:
  • abdominal organs in chest, “collar sign”
  • elevation of hemidiaphragm
  • indistinct diaphragmatic contour
  • pleural effusion or hemothorax
  • These findings have the following ddx:
  • atelectasis, lobar collapse
  • pulmonary contusion
  • loculated pneumothorax
  • pneumonia
  • phrenic nerve palsy
  • eventration
  • Any of the above ddx can also coexist with and obscure a real

diaphragmatic injury, so CT is often required for further evaluation.

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Erin Chen 2012 Gillian Lieberman, MD

  • Findings:
  • discontinuity of the diaphragm
  • thickening of diaphragm
  • herniation of abdominal contents, “collar sign”
  • abdominal organs contacting posterior ribs, “dependent organ sign”
  • Penetrating trauma is especially hard to see; up to 66% missed
  • Beware of positive pressure ventilation, which can push herniated organs

back down and give a false negative on imaging

Summary: CT diagnosis of diaphragmatic injury

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Acknowledgements

Gillian Lieberman, MD Annie Leylek, MD Attentive audience members!

Erin Chen 2012 Gillian Lieberman, MD

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Erin Chen 2012 Gillian Lieberman, MD

References

  • Sandstrom CK, Stern EJ. Diaphragmatic hernias: a spectrum of radiographic appearances. Curr Probl

Diagn Radiol. May-Jun 2011;40(3):95-115.

  • Nursal TZ, Ugurlu M, Kologlu M, Hamaloglu E. Traumatic diaphragmatic hernias: a report of 26 cases.
  • Hernia. Mar 2001;5(1):25-29.
  • Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg.

Nov 1995;60(5):1444-1449.

  • Williams M, Carlin AM, Tyburski JG, et al. Predictors of mortality in patients with traumatic diaphragmatic

rupture and associated thoracic and/or abdominal injuries. Am Surg. Feb 2004;70(2):157-162; discussion 162-153.

  • Turhan K, Makay O, Cakan A, et al. Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac
  • Surg. Jun 2008;33(6):1082-1085.
  • Tiryaki T, Livanelioglu Z, Atayurt H. Eventration of the diaphragm. Asian J Surg. Jan 2006;29(1):8-10.
  • Shanmuganathan K, Killeen K, Mirvis SE, White CS. Imaging of diaphragmatic injuries. J Thorac Imaging.

Apr 2000;15(2):104-111.

  • Murray JG, Caoili E, Gruden JF, Evans SJ, Halvorsen RA, Jr., Mackersie RC. Acute rupture of the

diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT. AJR Am J Roentgenol. May 1996;166(5):1035-1039.

  • Karmy-Jones R, Carter Y, Stern E. The impact of positive pressure ventilation on the diagnosis of

traumatic diaphragmatic injury. Am Surg. Feb 2002;68(2):167-172.

  • Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic injuries: spectrum of radiographic findings.
  • Radiographics. Jan-Feb 1998;18(1):49-59.