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| {{Infobox_Disease | | {{Infobox_Disease |
| | Name = Diaphragmatic rupture | | | Name = Diaphragmatic rupture |
| | Image = Diaphragmatic rupture spleen herniation.jpg | | | Image = Diaphragmatic rupture spleen herniation.jpg |
| | Caption = An [[X-ray]] showing the [[spleen]] in the left lower portion of the chest cavity (X and arrow) after a diaphragmatic tear<ref name="Hariharan06">{{cite journal |author=Hariharan D, Singhal R, Kinra S, Chilton A |title=Post traumatic intra thoracic spleen presenting with upper GI bleed! A case report |journal=BMC Gastroenterol |volume=6 |issue= |pages=38 |year=2006 |pmid=17132174 |pmc=1687187 |doi=10.1186/1471-230X-6-38 |url=http://www.biomedcentral.com/1471-230X/6/38}}</ref> | | | Caption = An [[X-ray]] showing the [[spleen]] in the left lower portion of the chest cavity (X and arrow) after a diaphragmatic tear<ref name="Hariharan06">{{cite journal |author=Hariharan D, Singhal R, Kinra S, Chilton A |title=Post traumatic intra thoracic spleen presenting with upper GI bleed! A case report |journal=BMC Gastroenterol |volume=6 |issue= |pages=38 |year=2006 |pmid=17132174 |pmc=1687187 |doi=10.1186/1471-230X-6-38 |url=http://www.biomedcentral.com/1471-230X/6/38}}</ref> |
| | DiseasesDB = <!--nothing found--> | | | DiseasesDB = | |
| | ICD10 = <!--nothing found--> | | | ICD10 = | |
| | ICD9 = {{ICD9|862.1}} | | | ICD9 = {{ICD9|862.1}} |
| | ICDO = {{ICD10|S|27|8|s|20}} | | | ICDO = {{ICD10|S|27|8|s|20}} |
| | OMIM = <!--na--> | | | OMIM = | |
| | MedlinePlus = <!--nothing found--> | | | MedlinePlus = | |
| | eMedicineSubj = med
| | | MeshID = | |
| | eMedicineTopic = 3487
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| | MeshID = <!--nothing found--> | |
| }} | | }} |
| {{SI}} | | {{Diaphragmatic rupture}} |
| {{CMG}} | | {{CMG}} |
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| {{EH}}
| | ==[[Diaphragmatic rupture overview|Overview]]== |
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| <!--Definition, causes-->
| | ==[[Diaphragmatic rupture historical perspective|Historical Perspective]]== |
| ==Overview== | |
| '''Diaphragmatic rupture''' (also called '''diaphragmatic injury''' or '''tear''') is a tear of the [[Thoracic diaphragm|diaphragm]], the muscle across the bottom of the ribcage that plays a crucial role in [[respiration]]. Most commonly, acquired diaphragmatic tears result from [[physical trauma]]. Diaphragmatic rupture can result from blunt or penetrating trauma<ref name="Sliker06">
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| {{
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| cite journal |author=Sliker CW |title=Imaging of diaphragm injuries |journal=Radiol Clin North Am |volume=44 |issue=2 |pages=199–211, vii |year=2006 |month=March |pmid=16500203 |doi=10.1016/j.rcl.2005.10.003 |url=
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| </ref> and occurs in about 5% of cases of severe blunt trauma to the trunk.<ref name="Nolan02">
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| {{
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| cite book |author=Nolan JP |chapter=Major trauma|editor=Adams AP, Cashman JN, Grounds RM |title=Recent Advances in Anaesthesia and Intensive Care: Volume 22 |publisher=Greenwich Medical Media |location=London |year=2002 |pages=182 |isbn=1-84110-117-6
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| }}
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| </ref>
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| <!--Diagnosis, rx-->
| | ==[[Diaphragmatic rupture classification|Classification]]== |
| Diagnostic techniques include [[X-ray]], [[computed tomography]], and surgical techniques such as [[laparotomy]]. Diagnosis is often difficult because signs may not show up on X-ray, or signs that do show up appear similar to other conditions. Signs and symptoms included chest and abdominal pain, difficulty breathing, and decreased lung sounds. When a tear is discovered, surgery is needed to repair it.
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| Injuries to the diaphragm are usually accompanied by other injuries, and they indicate that more severe injury may have occurred. The outcome often depends more on associated injuries than on the diaphragmatic injury itself.<ref name="Scharff07">
| | ==[[Diaphragmatic rupture pathophysiology|Pathophysiology]]== |
| {{
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| cite journal |author=Scharff JR, Naunheim KS |title=Traumatic diaphragmatic injuries |journal=Thorac Surg Clin |volume=17 |issue=1 |pages=81–5 |year=2007 |month=February |pmid=17650700 |doi= |url=
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| }}
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| </ref> Since the pressure is higher in the [[abdominal cavity]] than the [[chest cavity]], rupture of the diaphragm is almost always associated with herniation of abdominal organs into the chest cavity, called [[traumatic diaphragmatic hernia]].<ref name="McGillicuddy07"/> This herniation can interfere with breathing, and blood supply can be cut off to organs that herniate through the diaphragm, damaging them.
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| ==Signs and symptoms== | | ==[[Diaphragmatic rupture causes|Causes]]== |
| [[Breath sound]]s on the side of the rupture may be diminished, [[respiratory distress]] may be present, and the chest or abdomen may be painful.<ref name="Nolan02"/> [[Orthopnea]], [[dyspnea]] which occurs when lying flat, may also occur,<ref name="KarmyJurk04"/> and [[cough]]ing is another sign.<ref name="McGillicuddy07"/> In people with herniation of abdominal organs, signs of intestinal blockage or [[sepsis]] in the abdomen may be present.<ref name="McGillicuddy07"/> Bowel sounds may be heard in the chest, and shoulder or [[epigastric]] pain may be present.<ref name="Scharff07"/> When the injury is not noticed right away, the main symptoms are those that indicate [[bowel obstruction]].<ref name="Scharff07"/> | |
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| ==Causes== | | ==[[Diaphragmatic rupture differential diagnosis|Differentiating Diaphragmatic rupture from other Diseases]]== |
| The injury may be caused by [[blunt trauma]], [[penetrating trauma]], and by [[iatrogenic]] causes (as a result of medical intervention), for example during surgery to the abdomen or chest.<ref name="Scharff07"/> Injury to the diaphragm is reported to be present in 8% of cases of blunt chest trauma.<ref name="Weyant08"/> In cases of blunt trauma, vehicle accidents and falls are the most common causes.<ref name="Scharff07"/> Penetrating trauma has been reported to cause 12.3–20% of cases, but it has also been proposed as a more common cause than blunt trauma; discrepancies could be due to varying regional, social, and economic factors in the areas studied.<ref name="Sliker06"/> Stab and gunshot wounds can cause diaphragmatic injuries.<ref name="Scharff07"/> Clinicians are trained to suspect diaphragmatic rupture particularly if [[penetrating trauma]] has occurred to the lower [[chest]] or upper [[abdomen]].<ref name="Moore03"/> With penetrating trauma, the contents of the abdomen may not herniate into the chest cavity right away, but they may do so later, causing the presentation to be delayed.<ref name="Scharff07"/> Since the diaphragm moves up and down during breathing, penetrating trauma to various parts of the torso may injure the diaphragm; penetrating injuries as high as the third rib and as low as the twelfth have been found to injure the diaphragm.<ref name="Fleisher06">{{cite book |chapter=Thoracic trauma |editor=Fleisher GR, Ludwig S, Henretig FM, Ruddy RM, Silverman BK |title=Textbook of Pediatric Emergency Medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2006 |pages=1446–7 |isbn=0-7817-5074-1}}</ref>
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| ==Mechanism== | | ==[[Diaphragmatic rupture epidemiology and demographics|Epidemiology and Demographics]]== |
| Although the mechanism is unknown, it is proposed that a blow to the abdomen may raise the pressure within the abdomen so high that the diaphragm bursts.<ref name="Scharff07"/> Blunt trauma creates a large pressure gradient between the abdominal and thoracic cavities; this gradient, in addition to causing the rupture, can also cause abdominal contents to herniate into the thoracic cavity.<ref name="KarmyJurk04"/> Abdominal contents in the [[pleural cavity|pleural space]] interfere with breathing and cardiac activity.<ref name="KarmyJurk04"/> They can interfere with the return of blood to the heart and prevent the heart from filling effectively, reducing [[cardiac output]].<ref name="KarmyJurk04"/> If [[ventilation]] of the lung on the side of the tear is severely inhibited, [[hypoxemia]] (low blood oxygen) results.<ref name="KarmyJurk04"/>
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| Usually the rupture is on the same side as an impact.<ref name="Fleisher06"/> A blow to the side is three times more likely to cause diaphragmatic rupture than a blow to the front.<ref name="Fleisher06"/>
| | ==[[Diaphragmatic rupture risk factors|Risk Factors]]== |
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| ==Diagnosis== | | ==[[Diaphragmatic rupture screening|Screening]]== |
| Initially, diagnosis can be difficult, especially when other severe injuries are present; thus the condition is commonly diagnosed late.<ref name="Nolan02"/> [[Chest X-ray]] is known to be unreliable in diagnosing diaphragmatic rupture;<ref name="KarmyJurk04">
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| {{
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| cite journal |author=Karmy-Jones R, Jurkovich GJ |title=Blunt chest trauma |journal=Current Problems in Surgery |volume=41 |issue=3 |pages=211–380 |year=2004 |month=March |pmid=15097979 |doi=10.1016/j.cpsurg.2003.12.004 |quote=A sudden increase in the pressure gradient between the pleural and peritoneal cavities that occurs with high-speed blunt trauma will lead to disruptions of the diaphragm... This same pleuroperitoneal pressure gradient will also promote migration of intraperitoneal structures into the pleural space after disruption has occurred. Once the viscera have been displaced into the pleural space, both cardiovascular and respiratory functions are compromised.
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| </ref> it has low [[sensitivity]] and [[specificity]] for the injury.<ref name="McGillicuddy07"/> Often another injury such as [[pulmonary contusion]] masks the injury on the X-ray film.<ref name="Scharff07"/> Half the time, initial X-rays are normal; in most of those that are not, [[hemothorax]] or [[pneumothorax]] is present.<ref name="KarmyJurk04"/> However, there are signs detectable on X-ray films that indicate the injury. On an X-ray, the diaphram may appear higher than normal.<ref name="Nolan02"/> Gas bubbles may appear in the chest, and the [[mediastinum]] may appear shifted to the side.<ref name="Nolan02"/> A [[nasogastric tube]] from the stomach may appear on the film in the chest cavity; this sign is [[pathognomonic]] for diaphragmatic rupture, but it is rare.<ref name="KarmyJurk04"/> A [[contrast medium]] that shows up on X-ray can be inserted through the nasogastric tube to make a diagnosis.<ref name="Nolan02"/> The X-ray is better able to detect the injury when taken from the back with the patient upright, but this is not usually possible because the patient is usually not stable enough; thus it is usually taken from the front with the patient lying supine.<ref name="McGillicuddy07"/> [[Positive pressure ventilation]] helps keep the abdominal organs from herniating into the chest cavity, but this also can prevent the injury from being discovered on an X-ray.<ref name="KarmyJurk04"/>
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| [[Computed tomography]] has an increased accuracy of diagnosis over X-ray,<ref name="Weyant08"/> but no specific findings on a CT scan exist to establish a diagnosis.<ref name="Moore03"/> Although CT scanning increases chances that diaphragmatic rupture will be diagnosed before surgery, the rate of diagnosis before surgery is still only 31–43.5%.<ref name="Weyant08"/> Another diagnostic method is [[laparotomy]], but this misses diaphragmatic ruptures up to 15% of the time.<ref name="KarmyJurk04"/> Often diaphragmatic injury is discovered during a laparotomy that was undertaken because of another abdominal injury.<ref name="KarmyJurk04"/> [[Thoracoscopy]] is more reliable in detecting diaphragmatic tears than laparotomy and is especially useful when chronic diaphragmatic hernia is suspected.<ref name="KarmyJurk04"/> | | ==[[Diaphragmatic rupture natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| === Plain film === | | ==Diagnosis== |
| | | [[Diaphragmatic rupture history and symptoms| History and Symptoms]] | [[Diaphragmatic rupture physical examination | Physical Examination]] | [[Diaphragmatic rupture laboratory findings|Laboratory Findings]] | [[Diaphragmatic rupture x ray|X Ray]] | [[Diaphragmatic rupture CT|CT]] | [[Diaphragmatic rupture MRI|MRI]] | [[Diaphragmatic rupture ultrasound|Ultrasound]] | [[Diaphragmatic rupture other imaging findings|Other Imaging Findings]] | [[Diaphragmatic rupture other diagnostic studies|Other Diagnostic Studies]] |
| * Specific diagnostic findings of diaphragmatic tears on chest radiographs include the following:
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| ** Intrathoracic herniation of a hollow viscus (stomach, colon, small bowel) with or without focal constriction of the viscus at the site of the tear ([http://www.radswiki.net/main/index.php?title=Collar_sign&action=edit&redlink=1 collar sign])
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| ** Visualization of a nasogastric tube above the hemidiaphragm on the left side.
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| ===CT===
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| * Direct discontinuity of the hemidiaphragm
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| * Intrathoracic herniation of abdominal contents. The stomach and colon are the most common viscera to herniate on the left side and the liver is the most common viscus to herniate on the right side.
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| * The collar sign, a waistlike constriction of the herniating hollow viscus at the site of the diaphragmatic tear
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| * The dependent viscera sign. When a patient with a ruptured diaphragm lies supine at CT examination, the herniated viscera (bowel or solid organs) are no longer supported posteriorly by the injured diaphragm and fall to a dependent position against the posterior ribs.
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| <gallery>
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| Image:Diaphragmatic-rupture-001.jpg
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| Image:
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| Diaphragmatic-rupture-002.jpg | |
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| </gallery>
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| ===Location===
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| Between 50 and 80% of diaphragmatic ruptures occur on the left side.<ref name="McGillicuddy07">{{cite journal |author=McGillicuddy D, Rosen P |title=Diagnostic dilemmas and current controversies in blunt chest trauma |journal=Emerg Med Clin North Am |volume=25 |issue=3 |pages=695–711, viii–ix |year=2007 |month=August |pmid=17826213 |doi=10.1016/j.emc.2007.06.004 |url=}}</ref> It is possible that the [[liver]], which is situated in the right upper quadrant of the abdomen, cushions the diaphragm.<ref name="Scharff07"/> However, injuries occurring on the left side are also easier to detect in X-ray films.<ref name="KarmyJurk04"/> Half of diaphragmatic ruptures that occur on the right side are associated with liver injury.<ref name="McGillicuddy07"/> Injuries occurring on the right are associated with a higher rate of death and more numerous and serious accompanying injuries.<ref name="Fleisher06"/> Bilateral diaphragmatic rupture, which occurs in 1–2% of ruptures, is associated with a much higher death rate ([[mortality rate|mortality]]) than injury that occurs on just one side.<ref name="McGillicuddy07"/>
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| ==Treatment== | | ==Treatment== |
| Since the diaphragm is in constant motion with respiration, and because it is under tension, lacerations will not heal on their own.<ref name="Fleisher06"/> Surgery is needed to repair a torn diaphragm.<ref name="Nolan02"/> Most of the time, the injury is repaired during [[laparotomy]].<ref name="Moore03"/> Other injuries, such as [[hemothorax]], may present a more immediate threat and may need to be treated first if they accompany diaphragmatic rupture.<ref name="Scharff07"/> Video-assisted thoracoscopy may be used.<ref name="KarmyJurk04"/>
| | [[Diaphragmatic rupture medical therapy|Medical Therapy]] | [[Diaphragmatic rupture surgery|Surgery]] | [[Diaphragmatic rupture primary prevention|Primary Prevention]] | [[Diaphragmatic rupture secondary prevention|Secondary Prevention]] | [[Diaphragmatic rupture cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Diaphragmatic rupture future or investigational therapies|Future or Investigational Therapies]] |
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| ==Prognosis==
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| In most cases, isolated diaphragmatic rupture is associated with good outcome if it is surgically repaired.<ref name="Scharff07"/> The death rate ([[mortality rate|mortality]]) for diaphragmatic rupture after blunt and penetrating trauma is estimated to be 15–40% and 10–30% respectively, but other injuries play a large role in determining outcome.<ref name="Scharff07"/>
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| ===Complications===
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| A significant complication of diaphragmatic rupture is [[traumatic diaphragmatic herniation]]: organs such as the stomach that herniate into the chest cavity and may be strangulated, losing their blood supply.<ref name="Nolan02"/> Herniation of abdominal organs is present in 3–4% of people with [[abdominal trauma]] who present to a trauma center.<ref name="Moore03">
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| {{
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| cite book |chapter=Injury to the diaphragm |author = Asensio JA, Petrone P, Demitriades D, commentary by Davis JW |title=Trauma. Fifth Edition |editor=Moore EE, Feliciano DV, Mattox KL |year= 2003 |publisher= McGraw-Hill Professional | isbn= 0071370692 |pages=613–616
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| </ref>
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| ==Epidemiology==
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| Diaphragmatic injuries are present in 1–7% of people with significant blunt trauma<ref name="Scharff07"/> and an average of 3% of abdominal injuries.<ref name="Moore03"/> | |
| A high [[body mass index]] may be associated with a higher risk of diaphragmatic rupture in people involved in vehicle accidents.<ref name="Scharff07"/> It is rare for the diaphragm alone to be injured, especially in blunt trauma; other injuries are associated in as many as 80–100% of cases.<ref name="KarmyJurk04"/><ref name="Weyant08"/> In fact, if the diaphragm is injured, it is an indication that more severe injuries to organs may have occurred.<ref name="Weyant08">
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| {{
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| cite journal |author=Weyant MJ, Fullerton DA |title=Blunt thoracic trauma |journal=Seminars in Thoracic and Cardiovascular Surgery |volume=20 |issue=1 |pages=26–30 |year=2008 |pmid=18420123 |doi=10.1053/j.semtcvs.2008.01.002
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| </ref> Thus, the mortality after a diagnosis of diaphragmatic rupture is 17%, with most deaths due to lung complications.<ref name="Weyant08"/> Common associated injuries include [[head injury]], injuries to the [[aorta]], [[bone fracture|fractures]] of the [[pelvic fracture|pelvis]] and [[long bone]]s, and [[laceration]]s of the [[liver]] and [[spleen]].<ref name="KarmyJurk04"/> Associated injuries occur in over three quarters of cases.<ref name="Fleisher06"/>
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| ==History==
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| In 1579, [[Ambroise Paré]] made the first description of diaphragmatic rupture, in a French artillery captain who had been shot eight months before his death from complications of the rupture.<ref name="Moore03"/> Using autopsies, Paré also described diaphragmatic rupture in people who had suffered blunt and penetrating trauma.<ref name="Moore03"/> Reports of diaphragmatic herniation due to injury date back at least as far as the 17th century.<ref name="Moore03"/> Petit was the first to establish the difference between acquired and [[congenital diaphragmatic hernia]], which results from a congenital malformation of the diaphragm. In 1888, Naumann repaired a hernia of the stomach into the left chest that was caused by trauma.<ref name="Moore03"/>
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| ==References== | | ==Case Studies== |
| {{reflist}}
| | [[Diaphragmatic rupture case study one|Case#1]] |
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| {{chest trauma}}
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| {{SIB}}
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| [[Category:Chest trauma]] | | [[Category:Chest trauma]] |
| [[Category:Pulmonology]] | | [[Category:Pulmonology]] |
| | | [[Category:Disease]] |
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |
