186 lines
16 KiB
Markdown
186 lines
16 KiB
Markdown
---
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title: "Elevated or Deformed Hemidiaphragm"
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docid: "208baaa2-8772-4560-af34-46ce757edcb9"
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authors:
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- key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
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value: "Siva P. Raman, MD"
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breadcrumbs:
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-
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name: "Gastrointestinal"
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slug: "gastrointestinal"
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treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
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-
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name: "Abdominal Wall"
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slug: "abdominal-wall"
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treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
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-
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name: "Anatomically Based Differentials"
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slug: "anatomically-based-differentials"
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treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
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-
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name: "Elevated or Deformed Hemidiaphragm"
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slug: "elevated-or-deformed-hemidiaphragm"
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treeNodeId: null
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category: "Gastrointestinal"
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documentVersionId: "c5d9083d-d7a6-430b-9be6-4a6013d67387"
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imageCount: 18
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lastUpdated: "07/01/22"
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pageDescription: "Elevated or Deformed Hemidiaphragm"
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pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Elevated or Deformed Hemidiaphragm"
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pageTitle: "Elevated or Deformed Hemidiaphragm | STATdx"
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enhancedTitle: "Elevated or Deformed Hemidiaphragm"
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type: "DDX"
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references: true
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breadcrumbs:
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- "Gastrointestinal"
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- "Differential Diagnosis"
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- "Abdominal Wall"
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- "Anatomically Based Differentials"
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- "Elevated or Deformed Hemidiaphragm"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Axial CT suboptimal for distinguishing diaphragm from spleen, liver, and muscle and identifying many diaphragmatic abnormalities
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- Multiplanar reformations critical for accurate diagnosis
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- Diaphragm easier to visualize discretely on MR compared to CT and can demonstrate diaphragm in multiple planes
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- Fluoroscopy and US useful for providing functional information, particularly for paralysis
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- Dynamic MR (not widely utilized) can provide functional information similar to US or fluoroscopy
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- US in sagittal plane easily identifies diaphragm and location of peridiaphragmatic fluid collection
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- Ascites and abdominal contents lie medial to and within confines of diaphragm
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- Pleural fluid and thoracic contents lie outside confines of diaphragm
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- ## Helpful Clues for Common Diagnoses
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- **Paralyzed Diaphragm**
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- Normal diaphragm that fails to contract secondary to abnormalities of brain, spinal cord, neuromuscular junction, phrenic nerve, or muscle
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- US or fluoroscopy demonstrate no motion or paradoxical (upward) motion during inspiration or sniff test
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- **Eventration of Diaphragm**
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- Congenital thinning/weakness of portion of diaphragm, which normally attaches to costal margin
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- Eccentric diaphragmatic contour (usually anteromedial right hemidiaphragm) ± paradoxical motion with large eventrations
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- **Hiatal Hernia**
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- Herniation of abdominal contents into thoracic cavity through esophageal hiatus
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- Divided into sliding type (GE junction displaced upward through hiatus) and paraesophageal type (GE junction in normal location with stomach herniating above diaphragm)
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- **Bochdalek Hernia**
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- Type of congenital diaphragmatic hernia due to defect in posterolateral diaphragm (usually on left side)
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- Hernia may contain retroperitoneal fat, bowel, kidney, stomach, spleen, or liver
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- **Morgagni Hernia**
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- Type of congenital diaphragmatic hernia due to defect in retrosternal diaphragm (usually on right side)
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- Usually located in right cardiophrenic angle and most often contains just omental fat (but can contain colon, liver, small bowel, or stomach)
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- **Traumatic Diaphragmatic Hernia**
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- Traumatic injury may be due to blunt or penetrating trauma
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- Multiple imaging signs of injury include dependent viscus sign, collar sign, and dangling diaphragm sign
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- Injuries both above and below diaphragm should raise concern for diaphragmatic injury
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- **Subdiaphragmatic Mass**
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- Tumor, hepatomegaly, or splenomegaly can exert mass effect and raise ipsilateral diaphragm
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- **Abdominal****Abscess**
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- Subphrenic abscess can cause upward displacement of diaphragm due to mass effect or splinting (decreased motion of diaphragm due to pain)
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- **Unilateral Lung Volume Loss**
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- Diminished unilateral lung volume (lung resection, atelectasis) will cause elevation of ipsilateral diaphragm
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- **Subpulmonic Pleural Effusion (Mimic)**
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- Pleural fluid loculated in subpulmonic pleural space will displace lung upward and may simulate elevated diaphragm on radiographs (but not on cross-sectional imaging)
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## References
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# Selected References
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1. [Abdellatif W et al: Unravelling the mysteries of traumatic diaphragmatic injury: an up-to-date review. Can Assoc Radiol J. 71(3):313-21, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32157897%5Bpmid%5D)
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1. [Kharma N: Dysfunction of the diaphragm: imaging as a diagnostic tool. Curr Opin Pulm Med. 19(4):394-8, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23715292%5Bpmid%5D)
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1. [Nason LK et al: Imaging of the diaphragm: anatomy and function. Radiographics. 32(2):E51-70, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22411950%5Bpmid%5D)
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1. [Roberts HC: Imaging the diaphragm. Thorac Surg Clin. 19(4):431-50, v, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=20112626%5Bpmid%5D)
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1. [Verhey PT et al: Differentiating diaphragmatic paralysis and eventration. Acad Radiol. 2007 Apr;14(4):420-5](http://www.ncbi.nlm.nih.gov/pubmed/?term=17368210%5Bpmid%5D)
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1. [Eren S et al: Imaging of diaphragmatic rupture after trauma. Clin Radiol. 61(6):467-77, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16713417%5Bpmid%5D)
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1. [Eren S et al: Diaphragmatic hernia: diagnostic approaches with review of the literature. Eur J Radiol. 54(3):448-59, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15899350%5Bpmid%5D)
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## Images
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### Selected Images
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**Paralyzed Diaphragm**
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*Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm <img src='img/arrows/WS.png'/> is paralyzed due to phrenic nerve involvement by the patient's mediastinal lymphoma (not shown).*
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**Paralyzed Diaphragm**
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*Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm <img src='img/arrows/WS.png'/> is paralyzed due to phrenic nerve involvement by the patient's mediastinal lymphoma (not shown).*
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**Eventration of Diaphragm**
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*Coronal CECT shows the characteristic appearance of diaphragmatic eventration with focal scalloping of the right anterior hemidiaphragm and superior protrusion of the liver at the site of eventration <img src='img/arrows/WS.png'/>.*
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**Hiatal Hernia**
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*Coronal CECT shows a large hiatal hernia with the entirety of the stomach <img src='img/arrows/WS.png'/> located within the thoracic cavity.*
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**Bochdalek Hernia**
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*Sagittal CECT shows a large Bochdalek hernia containing bowel and kidney. There is focal interruption of the hemidiaphragm <img src='img/arrows/WO.png'/> with herniation of the kidney <img src='img/arrows/WS.png'/> into the thorax.*
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**Morgagni Hernia**
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*Coronal NECT shows a characteristic Morgagni hernia with omental fat herniating into the chest through a defect <img src='img/arrows/WS.png'/> in the right anteromedial diaphragm.*
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**Traumatic Diaphragmatic Hernia**
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*Sagittal T2 MR shows a posttraumatic defect <img src='img/arrows/WS.png'/> in the left hemidiaphragm with the stomach <img src='img/arrows/WO.png'/> herniating into the chest. Note that the diaphragm is identified as a low-signal curvilinear structure. The stomach is pinched as it traverses the defect in the diaphragm.*
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**Traumatic Diaphragmatic Hernia**
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*Axial CECT shows the fallen viscus sign associated with traumatic diaphragmatic injury. Note that the stomach <img src='img/arrows/WS.png'/> lies in the chest and has fallen medially and posteriorly to lie against the lung and the posteromedial chest wall.*
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**Subpulmonic Pleural Effusion (Mimic)**
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*Axial CECT shows a pleural effusion <img src='img/arrows/WS.png'/> below the lung and lateral to the diaphragm <img src='img/arrows/WC.png'/>. Ascites <img src='img/arrows/WO.png'/> lies medial to the diaphragm and adjacent to the cirrhotic liver.*
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### Additional Images
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**Paralyzed Diaphragm**
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*Axial NECT shows elevation of the left hemidiaphragm <img src='img/arrows/WS.png'/> without focal bulge or eventration. The abdominal contents do not fall dependently but are suspended by the intact diaphragm.*
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**Eventration of Diaphragm**
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*Sagittal CECT shows a focal bulge of the liver <img src='img/arrows/WO.png'/> through a weakened eventration of the right hemidiaphragm.*
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**Hiatal Hernia**
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*Axial NECT shows herniation of most of the stomach <img src='img/arrows/WO.png'/> as well as the splenic flexure of colon <img src='img/arrows/WS.png'/> through a massive hiatal hernia.*
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**Bochdalek Hernia**
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*Axial CECT shows bilateral defects <img src='img/arrows/WO.png'/> in the posteromedial portions of the diaphragm with herniation of omental fat.*
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**Morgagni Hernia**
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*Axial NECT shows a large hiatal hernia <img src='img/arrows/WO.png'/> that contains much of the stomach. There is also a large Morgagni hernia <img src='img/arrows/WS.png'/>, lateral to and displacing the heart, containing omental fat and colon.*
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**Traumatic Diaphragmatic Hernia**
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*Coronal T2 MR shows herniation of the stomach <img src='img/arrows/WO.png'/> and omental fat through a defect in the left hemidiaphragm <img src='img/arrows/WS.png'/>. The stomach is pinched as it traverses the defect in the diaphragm.*
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**Traumatic Diaphragmatic Hernia**
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*Axial CECT shows herniation of the stomach <img src='img/arrows/WS.png'/> through a defect in the left hemidiaphragm. The stomach has fallen to lie against the posteromedial chest wall and is pinched <img src='img/arrows/WC.png'/>.*
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**Hiatal Hernia**
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*Coronal CECT shows a large hiatal hernia with the entirety of the stomach <img src='img/arrows/WS.png'/> located within the thoracic cavity.*
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**Paralyzed Diaphragm**
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*Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm <img src='img/arrows/WS.png'/> is paralyzed as a result of phrenic nerve involvement by a mediastinal soft tissue mass <img src='img/arrows/WC.png'/> in this patient with metastatic lung cancer.*
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**Bochdalek Hernia**
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*Sagittal CECT shows a large Bochdalek hernia containing bowel and kidney. There is focal interruption of the hemidiaphragm <img src='img/arrows/WO.png'/> with herniation of the kidney <img src='img/arrows/WS.png'/> into the thorax.*
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