Traumatic Diaphragmatic Rupture

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1 Beth Israel Deaconess Medical Center Harvard Medical School December 2009 Traumatic Diaphragmatic Rupture Kapil Verma, Harvard Medical School Year III Gillian Lieberman, MD

2 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

3 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

4 Background: Epidemiology of Traumatic Diaphragmatic Rupture Trauma is the 4th most common cause of death in the USA and the leading cause of fatalities in those younger than 45 years-old Traumatic diaphragmatic rupture (TDR) injuries occur in 0.8 to 8% of patients who sustain blunt (MVC and fall from height) and penetrating trauma Mortality from TDR is 14-50%. This increases to 77% when associated with shock and head injury Sangster G, Ventura V, Carbo A, et. al

5 Background: Complications and common associations of TDR Diagnosis of TDR missed in up to 48% of blunt trauma patients on routine chest films and 30% of body CT scans. Failure to identify the abnormality may cause acute or delayed severe complications Cardiovascular-respiratory respiratory insufficiency Bowel strangulation and ischemia Left hemidiaphragm injured 4 times more commonly than the right. Bilateral cases are rare (5-8%) Most commonly herniated organs: stomach > small and large bowel > spleen > liver Associated intra-abdominal abdominal injuries common (75% of TDR patients have associated intra- abdominal injury) Eren S, Kantarci M, Okur A.

6 Background: Clinical symptoms as poor indicators of detecting TDR Most commonly experienced clinical symptoms of TDR include dyspnea,, chest pain, abdominal pain, vomiting The clinical diagnosis of TDR is difficult and missed in up to 65% of patients Therefore, imaging is essential Sangster G, Ventura V, Carbo A, et. al

7 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

8 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

9 Menu of Tests: Plain Chest Film Plain film chest radiography 1 st test of choice to evaluate suspected TDR Sensitivity of the chest plain film for the detection of the DR range from 27 to 60% for left-sided hernias and 17 to 33% for the right The most specific radiographic findings of DR include intrathoracic herniation of hollow viscera (small bowel, stomach, or colon) and identification of the nasogastric tube above the level of the left hemidiaphragm Gelman R, Mirvis SE, Gens D.

10 Menu of Tests: Plain Chest Film, differential diagnosis for NG tube seen in left thorax Differential diagnosis for NG tube tip overlying the chest on plain film: 1) Tip is still inside the stomach diaphragmatic rupture 2) Tip is outside of the GI tract in a bronchus or the pleural space 3) Tube is outside the patient Supine AP Portable Plain Chest Film with NG tube tip in left thorax

11 Menu of Tests: Plain Chest Film, Limitations Failure to diagnose TDR on plain films range from 12 to 66% Concurrent pulmonary abnormalities such as pleural effusion, pulmonary contusion and atelectasis can mimic or mask TDR on plain chest films A herniation at the costo-phrenic angle may be misdiagnosed as a pleural effusion or hemothorax on the initial chest radiograph, and a thoracic drainage tube could accidentally be placed into the herniated organs Shapiro MJ, Heidberg E, Durham RM, et. al.

12 Menu of Tests: CT Multidetector CT (MDCT) has TDR detection rates of 73 92% = Gold standard for diagnosis Because TDR is rarely isolated, CT is advantageous in the evaluation of other associated injuries Nchimi A, Szapiro D, Ghaye B, et. al.

13 Menu of Tests: CT Findings for TDR Diaphragm discontinuity and Dangling diaphragm sign 73% sensitivity, 90% specificity Intrathoracic herniation of abdominal contents 55% sensitivity, 100% specificity Collar sign: Constriction of the herniated abdominal viscera 67% sensitivity, 100% specificity Dependent viscera sign: Visualization of the herniated viscera against the posterior chest wall 100% sensitivity, 90% specificity Desser TS. Edwards B, Hunt S, et. al.

14 Companion Patient 1: The Collar and Dangling Diaphragm Signs on CT Axial contrast CT through the abdomen. Arrowhead shows construction of the stomach as it passes through the diaphragmatic defect, this is the Collar sign. The relatively newly discovered dangling diaphragm sign is seen with the arrow, representing the torn free edge of the left hemidiaphragm Axial C+ CT through abdomen Desser TS. Edwards B, Hunt S, et. al.

15 Companion Patient 2: The Dependent Viscera Sign on CT Axial contrast CT through the thorax, showing the Dependent viscera sign. The stomach is lying adjacent to the posterior ribs instead of within the expected confines of the dome of the diaphragm Axial C+ CT through thorax Desser TS. Edwards B, Hunt S, et. al; Bergin D, Ennis R, Keogh C, et. al.

16 Menu of Tests: Lesser Used Studies to evaluate TDR A barium study can be performed as a complement to diagnosis if the patient can tolerate the study. If intestinal passage is normal, barium filling intestinal loops are detected within the thorax MRI also used, but not a practical imaging technique in acute emergency setting for multi- trauma patients, as it is a slower modality than CT Surgical laparotomy may detect any unseen, subtle tears in the diaphragm. Preferred over thoracotomy Sangster G, Ventura V, Carbo A, et. al.

17 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

18 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

19 Our Patient J.C: History of Present Illness 23 M helmeted, riding a scooter at 15 mph struck by a motor vehicle and thrown from scooter 10 feet No LOC, with GCS of 14 at scene Negative FAST ultrasound

20 Our Patient J.C: Plain Chest Film PACS, BIDMC AP Supine Portable Chest Film

21 Patient J.C: Plain Chest Film Findings AP chest supine plain film Lungs are clear with no pneumothorax The right hemidiaphragm appears intact Partial herniation of the stomach into the chest AP Supine Portable Chest Film Detailed evaluation limited by underlying trauma board PACS, BIDMC

22 Our Patient J.C: CT Scout Image PACS, BIDMC CT C- Scout Image

23 Our Patient J.C: CT Axial Image PACS, BIDMC CT C+ Axial Image through the thorax

24 Our Patient J.C: CT Axial Image Findings Confirmation of herniation of stomach partially into the thorax CT C+ Axial Image through the thorax No comment made about potential liver elevation from axial images PACS, BIDMC

25 Our Patient J.C: CT Sagittal Image PACS, BIDMC Sagittal C+ CT image through level of the stomach and left hemidiaphragm

26 Our Patient J.C: CT Sagittal Image Findings Discontinuity of left hemidiaphgragm with herniation of stomach into left chest PACS, BIDMC Sagittal C+ CT image through level of the stomach and left hemidiaphragm

27 Normal Patient vs. Our Patient J.C: CT Sagittal Images NORMAL OUR PATIENT J.C. PACS, BIDMC Sagittal C+ CT images through level of the liver Normal patient on the left, Our Patient J.C on the right

28 NORMAL Normal Patient vs. Our Patient J.C: CT Sagittal Image Findings OUR PATIENT J.C. Elevation of the dome of the liver into the chest in patient JC, compared to normal smooth confines of upper dome of liver in normal patient on the left Confirmation of right hemidiaphragm tear with herniation of dome of liver not made on imaging, but later by the surgeon during emergency laparotomy Sagittal C+ CT images through level of the liver Normal patient on the left, Our Patient J.C on the right PACS, BIDMC

29 Our Patient J.C: Post diaphragmatic repair CXR and CT PACS, BIDMC Upright plain film of the chest Sagittal C+ CT Image through the liver

30 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

31 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

32 Companion Patient A.B. 22 M unrestrained rear seat passenger in high speed MVC, with GCS of 5 at scene Rhonchi appreciated in left lung on auscultation

33 Companion Patient A.B: Plain Chest Film PACS, BIDMC AP Supine Portable Chest Film

34 Companion Patient A.B: Plain Chest Film Findings AP chest supine plain film Complete opacification of the left chest. Multiple rib fractures including 2 nd, 3 rd, 4 th left ribs The mediastinum is shifted to the right Impression: Given the trauma history this could well represent pulmonary contusion or hemorrhage AP Supine Portable Chest Film PACS, BIDMC

35 Companion Patient A.B: CT Scout Image Left diaphragm rupture with herniation of the spleen, stomach, small bowel and a portion of the large bowel into the left thorax PACS, BIDMC CT C- Scout Image

36 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

37 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

38 Embryology of the Diaphragm The diaphragm is created by the fusion of four discrete structures at the 7th week of development: Septum transversum Pleuroperitoneal membrane Lateral body wall mesoderm Dorsal mesentery Several Parts Make the Diaphragm Sugarbaker DJ: Adult Chest Surgery,

39 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

40 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

41 Diaphragmatic Trauma Fake-out 1: Congenital Hernias Bochdalek (90%) Back of diaphragm, left (5:1) Posterolateral and result from failed fusion of pleuroperitoneal folds at the eighth week of gestation Morgagni Middle of diaphragm Foramen of Morgagni hernias are located posterior to the xiphoid process and are caused by failed migration of the cervical somites Hanna W, Ferri L, Fata P, et. Al.

42 Diaphragmatic Trauma Fake-out 1: Congenital Hernias on CXR In newborns, if massive defect, apparent on plain film; morbidity related to degree of pulmonary hypoplasia Supine plain film of the chest; Bochdalek hernia Differentiate from TDR by absence of trauma Images courtesy of Dr. Julia Rissmiller, BIDMC Supine plain film of the chest; Morgagni hernia

43 Diaphragmatic Fake-out 2: Diaphragmatic Eventration Congenital absence of functional diaphragmatic musculature with incomplete muscularization of the diaphragm and a thin membranous sheet replacing a portion of the diaphragmatic muscle Frequently involves the anteromedial portion of the right hemidiaphragm Diaphragm retains its continuity and attachments to the costal margin Weakened hemidiaphragm is displaced into the thorax, which can compromise breathing Sangster G, Ventura V, Carbo A, et. al.

44 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

45 Agenda Background Menu of Tests Patient J.C. Companion Patient A.B. Embryology of the Diaphragm Diaphragmatic Trauma Fake-outs Conclusions

46 Conclusions TDR is an uncommon injury (0.8 8% of traumas), but with a high mortality (14-50%) TDR is difficult to diagnose clinically, and frequently missed on supine plain films CT is the gold standard noninvasive diagnostic modality and allows visualization of other associated intra-abdominal abdominal injuries Beware TDR fake-outs in the absence of trauma: congenital hernias and diaphragmatic eventration Always wear a seatbelt

47 Acknowledgements Gillian Lieberman, MD Diana Ferris, MD Julia Rissmiller,, MD James Kang, MD Maria Levantakis

48 References 1. Sangster G, Ventura V, Carbo A, et. al. Diaphgragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients. Am Soc Emergency Radiol 2007; 13(5): Eren S, Kantarci M, Okur A. Imaging of diaphragmatic rupture after trauma. Clin Radiol 2006; 61(6): Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR 1991; 156: Nchimi A, Szapiro D, Ghaye B, et. al. Helical CT of blunt diaphragmatic rupture. AJR 2005; 184: Shapiro MJ, Heidberg E, Durham RM, et. al. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol 1996; 51: Larici AR, Gotway MB, Litt HI, et. al. Helical CT with sagittal and coronal reconsutructions: accuracy for detection of diaphragmatic injury. AJR 2002; 179: Bergin D, Ennis R, Keogh C, et. al. The dependent viscera sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR 2001; 177: Desser TS. Edwards B, Hunt S, et. al. The dangling diaphragm sign: sensitivity and comparison with existing CT signs of blunt traumatic diaphragmatic rupture. Emerg Radiol 2010; 17(1): Hanna W, Ferri L, Fata P, et. al. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg 2008; 85: Reda E. Al-Refaie, Ebrahim Awad, Ehab M. Mokbel. Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients. Interact CardioVasc Thorac Surg 2009; 9:45-49.

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