Traumatic diaphragmatic hernia
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Awni D. Shahait, M.D.[2], The University of Jordan
Overview
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Awni D. Shahait, M.D.[2], The University of Jordan
Overview
A traumatic diaphragmatic hernia is a type of diaphragmatic hernia which is acquired through an abdominal injury. This is in contrast to a congenital diaphragmatic hernia, which is present from birth.
Historical Perspective
Traumatic diaphragmatic hernia apparently was described by Sennertus, who in 1541 reported an instance of delayed herniation of viscera through an injured diaphragm.[1] Ambroise Paré, in 1579, described the first case of diaphragmatic rupture diagnosed at autopsy. The first successful diaphragmatic repair was reported by Riolfi in 1886 in a patient with omental prolapse, and Naumann in 1888 repaired the defect with herniated stomach.
Differentiating Traumatic Diaphragmatic Hernia from other Diseases
Traumatic rupture of the diaphragm must be differentiated from atelectasis, space-consuming tumors of the lower pleural space, pleural effusion, and intestinal obstruction due to other causes.
Epidemiology and Demographics
Diaphragmatic injury accounts for 0.8-1.6% of blunt trauma abdomen. Approximately 4-6% of patients who undergo surgery for trauma have a diaphragmatic injury.[2]
Natural History, Complications and Prognosis
Hemorrhage and obstruction may occur. If herniation is massive, progressive cardiorespiratory insufficiency may threaten life. The most severe complication is strangulating obstruction of the herniated viscera. Surgical repair of the rent in the diaphragm is curative, and the prognosis is excellent. The diaphragm supports sutures well, so that recurrence is practically unknown.
Diagnosis
Chest X Ray
Plain films of the chest may show a radiopaque area and occasionally an air-fluid level if hollow viscera have herniated. If the stomach has entered the chest, the abnormal path of a nasogastric tube may be diagnostic. The collar sign is seen when abdominal contents are seen in the thorax with/without focal constriction. Elevation and distortion of the hemi diaphragm are corroborative signs.[3]
CT
CT scan may demonstrate the diaphragmatic rent. A CT thorax has a sensitivity of 14-82% and a specificity of 87% and permits direct visualization of the contents and the rupture. Focused abdominal sonography for trauma (FAST) is now a good aid in diagnosing diaphragmatic hernia.[4]
MRI
MRI may demonstrate the diaphragmatic rent.
Ultrasound
Ultrasound may demonstrate the diaphragmatic rent.
Other Imaging Findings
Barium study of the colon may show irregular patches of barium in the colon above the diaphragm or a smooth colonic outline if the colon does not contain feces.
Treatment
Surgery
For acute ruptures, a transabdominal (most commonly) or transthoracic route is used depending on the procedure required to treat ancillary injuries. When the diaphragmatic tear is the only injury, it is usually fixed by laparotomy. Chronic injuries can be repaired by either approach. Asymptomatic tears of the diaphragm with herniated viscera should be repaired, because the risk of a strangulating obstruction is high.
References
- ↑ Shah R, Sabanathan S, Mearns AJ, Choudhury AK (1995). “Traumatic rupture of diaphragm”. Ann. Thorac. Surg. 60 (5): 1444–9. doi:10.1016/0003-4975(95)00629-Y. PMID 8526655. Unknown parameter
|month=ignored (help) - ↑ Ala-Kulju K, Verkkala K, Ketonen P, Harjola PT (1986). “Traumatic rupture of the right hemidiaphragm”. Scand J Thorac Cardiovasc Surg. 20 (2): 109–14. PMID 3738439.
- ↑ Shackleton KL, Stewart ET, Taylor AJ (1998). “Traumatic diaphragmatic injuries: spectrum of radiographic findings”. Radiographics. 18 (1): 49–59. PMID 9460108.
- ↑ Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K (2004). “Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma”. Am J Emerg Med. 22 (7): 601–4. PMID 15666270. Unknown parameter
|month=ignored (help)
Historical Perspective
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Awni D. Shahait, M.D.[2], The University of Jordan
Overview
Traumatic diaphragmatic hernia apparently was described by Sennertus, who in 1541 reported an instance of delayed herniation of viscera through an injured diaphragm.[1] Ambroise Paré, in 1579, described the first case of diaphragmatic rupture diagnosed at autopsy. The first successful diaphragmatic repair was reported by Riolfi in 1886 in a patient with omental prolapse, and Naumann in 1888 repaired the defect with herniated stomach.
References
Pathophysiology
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Awni D. Shahait, M.D.[2], The University of Jordan
Pathophysiology
Diaphragmatic injuries are caused either by penetrating or blunt injuries to the abdomen. They are diagnosed immediately as part of multi-organ injury, or present later either with respiratory distress or as intestinal obstruction.[1] The mechanism in blunt injury is explained by shearing of a stretched membrane, avulsion at the point of diaphragmatic attachment, and the sudden force transmission through viscera acting as viscous fluid. Left sided injuries are more often seen. Left-sided rupture occurred in 68.5% of the patients, 24.2% had right-sided rupture, 1.5% had bilateral rupture, 0.9% had pericardial rupture, and 4.9% were unclassified.[2] Increased strength of the right hemi-diaphragm, hepatic protection of the right side, under diagnosis of right-sided ruptures, and weakness of the left hemi-diaphragm at points of embryonic fusion all have been proposed to explain the predominance of left sided diaphragmatic injuries.[2] Autopsy studies reveals that the incidence of rupture is almost equal on both sides but the greater force needed for the right rupture. A positive pressure gradient of 7-20 cms of H2O between the intraperitoneal and the intra pleural cavities forces the contents into the thorax. With severe blunt trauma the pressures may rise to as high as 100cms of water.
It can occur after splenectomy.[3]
Because it can be indicative of severe trauma, it often co-presents with pelvic fracture.[4]
References
- ↑ CARTER BN, GIUSEFFI J, FELSON B (1951). “Traumatic diaphragmatic hernia”. Am J Roentgenol Radium Ther. 65 (1): 56–72. PMID 14799666. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Ala-Kulju K, Verkkala K, Ketonen P, Harjola PT (1986). “Traumatic rupture of the right hemidiaphragm”. Scand J Thorac Cardiovasc Surg. 20 (2): 109–14. PMID 3738439.
- ↑ Tsuboi K, Omura N, Kashiwagi H, Kawasaki N, Suzuki Y, Yanaga K (2008). “Delayed traumatic diaphragmatic hernia after open splenectomy: report of a case”. Surg. Today. 38 (4): 352–4. doi:10.1007/s00595-007-3627-0. PMID 18368327.
- ↑ Meyers BF, McCabe CJ (1993). “Traumatic diaphragmatic hernia. Occult marker of serious injury”. Ann. Surg. 218 (6): 783–90. PMC 1243075. PMID 8257229. Unknown parameter
|month=ignored (help)
Causes
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References
Differentiating Traumatic Diaphragmatic Hernia from other Diseases
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Awni D. Shahait, M.D.[2], The University of Jordan
Overview
Traumatic rupture of the diaphragm must be differentiated from atelectasis, space-consuming tumors of the lower pleural space, pleural effusion, and intestinal obstruction due to other causes.
References
Epidemiology and Demographics
Please help WikiDoc by adding more content here. It’s easy! Click here to learn about editing.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Awni D. Shahait, M.D.[2], The University of Jordan
Overview
Diaphragmatic injury accounts for 0.8-1.6% of blunt trauma abdomen. Approximately 4-6% of patients who undergo surgery for trauma have a diaphragmatic injury.[1]
References
Risk Factors
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References
Natural History, Complications and Prognosis
Please help WikiDoc by adding more content here. It’s easy! Click here to learn about editing.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Awni D. Shahait, M.D.[2], The University of Jordan
Overview
Hemorrhage and obstruction may occur. If herniation is massive, progressive cardiorespiratory insufficiency may threaten life. The most severe complication is strangulating obstruction of the herniated viscera. Surgical repair of the rent in the diaphragm is curative, and the prognosis is excellent. The diaphragm supports sutures well, so that recurrence is practically unknown.
References
Diagnosis
Diagnosis
History and Symptoms | Physical Examination | Laboratory Findings | Chest X Ray | CT | MRI | Ultrasound | Other Imaging Findings | Other Diagnostic Studies
Treatment
Treatment
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies
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