Enter modality here Enter modality here, enter none if none. Principal Modality (2): Case Report # [] Date accepted: April 2015

Transcription

1 Radiological Category: Enter category here Principal Modality (1): Principal Modality (2): Enter modality here Enter modality here, enter none if none Case Report # [] Submitted by: Varun Rachakonda, M.D. Faculty reviewer: Naga Ramesh Chinapuvvula, M.D Date accepted: April 2015

2 Case History 52 yo female s/p MVC as a restrained passenger (-LOC, + seatbelt) who presented to OSH ED with abdominal pain. Positive FAST. Intubated at the OSH and transferred to MHH for continuing care

3 Radiological Presentations CXR - Portable AP

4 Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. Subpulmonic effusion Diaphragmatic eventration Hydrothorax Diaphragmatic rupture Paralyzed diaphragm Subdiaphragmatic mass

5 Radiological Presentations

6 Radiological Presentations

7 Radiological Presentations

8 Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. Lung tumor Diaphragmatic eventration Morgagni hernia Diaphragmatic rupture Paralyzed diaphragm Bochdalek hernia Extraplerual mass

9 Findings: Chest XR: 1. Elevation of the right hemidiaphragm. 2. Lateral blunting of the right costophrenic angle 3. Mild patchy consolidation in the right lung base CT Chest/Abdomen/Pelvis* : 1. Traumatic right hemidiaphragm rupture with herniation of the liver into the right hemithorax. 2. Grade 3 liver injury without evidence of active extravasation 3. Extensive free gas scattered throughout abd/pelvis with thickening of duodenum and jejunum, concerning for bowel perforation. Differentials: Diaphragmatic eventration Morgagni hernia Diaphragmatic rupture Bochdalek hernia Findings and Differentials *Additional findings not pertinent to case not included

10 Discussion Diaphragmatic rupture often caused by blunt and penetrating trauma 90-98% occur on the left: usually posterolateral part of diaphragm, medial to spleen Herniated organs: Stomach > omentum, colon, small bowel, spleen, liver Plain films: Lower thoracic abnormal gas density Herniation of hollow viscus CT: Discontinuity of hemidiaphragm, intrathoracic herniation of abdominal contents Collar sign : waist-like constriction of stomach or colon at site of diaphragmatic tear On the right side, waist-like constriction of the liver may be seen Fallen or dependent viscus sign: Herniated viscus abuts posterior ribs, spine, thoracic wall Dangling diaphragm sign: Free edge of torn diaphragm curls inward May be associated with rib fractures and hydropneumothroax Accuracy of CT ~ 80%

11 Collar sign Discussion CT signs

12 Discussion Fallen or dependent viscus sign

13 Dangling diaphragm sign Discussion

14 Discussion Differential Diagnosis Diaphragmatic eventration hypoplastic diaphragm, more common on right anterior portion No defect, collar sign, or fallen viscus sign Paralyzed Diaphragm Elevated but intact diaphragm. No characteristic signs Pleural effusion or extrapleural mass Can mask/mimic traumatic diaphragmatic hernia on plain films, but not CT Bochdalek Hernia Congenital defect in posteromedial diaphragm. No history of trauma Morgagni Hernia Anteromedial parasternal defect of diaphragm. No history of trauma

15 Traumatic right hemidiaphragmatic rupture Diagnosis

16 References Desir A, Ghaye B. CT of blunt diaphragmatic rupture. RadioGraphics 32: pp Bergin D et al: The "dependent viscera" sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR Am J Roentgenol. 177(5): , 2001 Iochum S et al: Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics. 22 Spec No:S103-16; discussion S116-8, 2002 Killeen KL et al: Helical CT of diaphragmatic rupture caused by blunt trauma. AJR Am J Roentgenol. 173(6):1611-6, 1999 Oikonomou A, Prassopoulos P. CT imaging of blunt chest trauma. Insights Imaging Jun;2(3) Epub 2011 Feb 11. Rees O et al: Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review of 12 cases. Clin Radiol. 60(12):1280-9, 2005