Diaphragmatic rupture

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Diaphragmatic rupture
13017 2010 Article 183 Fig1 HTML (1).jpg
An X-ray showing a raised diaphragm on the right [1]
Specialty Cardiothoracic surgery   OOjs UI icon edit-ltr-progressive.svg
Symptoms Difficulty breathing, chest pain
CausesTrauma
Diagnostic method Laparotomy, CT scan, X-ray
TreatmentSurgery
Prognosis 15–40% mortality rate

Diaphragmatic rupture (also called diaphragmatic injury or tear) is a tear of the diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in breathing. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from blunt or penetrating trauma and occurs in about 0.5% of all people with trauma. [2]

Contents

Diagnostic techniques include X-ray, computed tomography, and surgical techniques such as an explorative surgery. 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 include chest and abdominal pain, difficulty breathing, and decreased lung sounds. When a tear is discovered, surgery is needed to repair it.

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. 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, which is called a diaphragmatic hernia. This herniation can interfere with breathing.

Signs and symptoms

Symptoms may include pain, [3] orthopnea, (shortness of breath when lying flat), [4] and coughing. In people with herniation of abdominal organs, signs of intestinal blockage or sepsis in the abdomen may be present. [5] Bowel sounds may be heard in the chest, and shoulder or epigastric pain may be present. When the injury is not noticed right away, the main symptoms are those that indicate bowel obstruction. [6]

Causes

Diaphragmatic rupture 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. [6] It has also occurred spontaneously at the time of pregnancy or for no discernible reason. [2] Injury to the diaphragm is reported to be present in 8% of cases of blunt chest trauma. [7] In cases of blunt trauma, vehicle accidents and falls are the most common causes. [6] 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. [8] Stab and gunshot wounds can cause diaphragmatic injuries. [6] Clinicians are trained to suspect diaphragmatic rupture particularly if penetrating trauma has occurred to the lower chest or upper abdomen. [9] 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. [6] 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. [10] Iatrogenic cases have occurred as a complication of medical procedures involving the thorax or abdomen. It has occurred as a complication of thoracentesis and radiofrequency ablation. [2]

Mechanism

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 ruptures. [6] 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. Abdominal contents in the pleural space interfere with heart function and lung function. High intrathoracic pressure results in an increase in right atrial pressure, disrupting the filling of the heart and venous return of blood. [4] As venous return determines cardiac output, this results in a reduction of cardiac output. [11] If ventilation of the lung on the side of the tear is severely inhibited, hypoxemia (low blood oxygen) results. [4] Usually, the rupture is on the same side as an impact. [10] A blow to the side is three times more likely to cause diaphragmatic rupture than a blow to the front. [10]

Diagnosis

Physical examinations are not accurate, as there is usually no specific physical sign that can be used to diagnose this condition. [3] Thoracoscopic and laparoscopic methods can be accurate. [12] Chest X-ray is known to be unreliable in diagnosing diaphragmatic rupture; [4] it has low sensitivity and specificity for the injury. [5] Often another injury such as pulmonary contusion masks the injury on the X-ray film. [6] Half the time, initial X-rays are normal; in most of those that are not, hemothorax or pneumothorax is present. [4] 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. [4] The X-ray is better able to detect the injury when taken from the back with the person upright, but this is not usually possible because the person is usually not stable enough; thus it is usually taken from the front with the person lying supine. [5] 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. [4]

Axial lower chest CT scan showing bowel herniation due to left diaphragmatic rupture PMC2739847 1749-7922-4-32-2.png
Axial lower chest CT scan showing bowel herniation due to left diaphragmatic rupture

A CT scan has an increased accuracy of diagnosis over X-ray, [7] but no specific findings on a CT scan exist to establish a diagnosis. [9] The free edge of a ruptured diaphragm may curl and become perpendicular to the chest wall, a sign known as a dangling diaphragm. A herniated organ may constrict at the location of a rupture, a sign known as the collar sign. If the liver herniates through a rupture on the right side, it may produce two signs known as the hump and band signs. The hump sign is a form of the collar sign on the right. The band sign is a bright line that intersects the liver. it is believed to result due to the ruptured diaphragm compressing. [13] 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%. [7] Another diagnostic method is laparotomy, but this misses diaphragmatic ruptures up to 15% of the time. [4] Often diaphragmatic injury is discovered during a laparotomy that was undertaken because of another abdominal injury. [4] Because laparotomies are more common in those with penetrating trauma than compared to those who experienced a blunt force injury, diaphragmatic rupture is found more often in these people. [14] Thoracoscopy is more reliable in detecting diaphragmatic tears than laparotomy and is especially useful when chronic diaphragmatic hernia is suspected. [4]

Location

Between 50 and 80% of diaphragmatic ruptures occur on the left side. [5] It is possible that the liver, which is situated in the right upper quadrant of the abdomen, cushions the diaphragm. [6] However, injuries occurring on the left side are also easier to detect in X-ray films. [4] Half of diaphragmatic ruptures that occur on the right side are associated with liver injury. [5] Injuries occurring on the right are associated with a higher rate of death and more numerous and serious accompanying injuries. [10] Bilateral diaphragmatic rupture, which occurs in 1–2% of ruptures, is associated with a much higher death rate (mortality) than injuries that occur on just one side. [5]

Treatment

Left posterior diaphragmatic rupture undergoing surgery PMC3160360 1749-7922-6-23-3.png
Left posterior diaphragmatic rupture undergoing surgery

Since the diaphragm is in constant motion with respiration, and because it is under tension, lacerations will not heal on their own. [10] The injury usually becomes larger with time if not repaired. [2] The main goals of surgery are to repair any injuries to the diaphragm and to move any herniated abdominal organs back to their original place. [12] This is done by debriding nonviable tissue and closing the rupture. [3] Most of the time, the injury is repaired during laparotomy. [9] Early surgery is important, as diaphragmatic atrophy and adhesions occur over time. Sutures are used in the repair. [12] Other injuries, such as hemothorax, may present a more immediate threat and may need to be treated first if they accompany diaphragmatic rupture. [6] Video-assisted thoracoscopy may be used. [4]

Prognosis

In most cases, isolated diaphragmatic rupture is associated with good outcome if it is surgically repaired. [6] The death 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. [6] Herniation of abdominal organs is present in 3–4% of people with abdominal trauma who present to a trauma center. [9]

Epidemiology

Diaphragmatic injuries are present in 1–7% of people with significant blunt trauma [6] and an average of 3% of abdominal injuries. [9] A high body mass index may be associated with a higher risk of diaphragmatic rupture in people involved in vehicle accidents. [6] Over 90% occur due to trauma from vehicle accidents. Due to the great force needed to rupture the diaphragm, [3] 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. [4] [7] In fact, if the diaphragm is injured, it is an indication that more severe injuries to organs may have occurred. Thus, the mortality after a diagnosis of diaphragmatic rupture is 17%, with most deaths due to lung complications. [7] Common associated injuries include head injury, injuries to the aorta, fractures of the pelvis and long bones, and lacerations of the liver and spleen. [4] Associated injuries occur in over three quarters of cases. [10]

Ambroise Pare Ambroise Pare.jpg
Ambroise Paré

History

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. He died from complications of the rupture. Using autopsies, Paré also described diaphragmatic rupture in people who had suffered blunt and penetrating trauma. Reports of diaphragmatic herniation due to injury date back at least as far as the 17th century. 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. [9]

Other animals

Diaphragmatic rupture in a dog Diaphragmatic-rupture dog.jpg
Diaphragmatic rupture in a dog

Diaphragmatic rupture is a common and well-known complication of blunt abdominal trauma in cats and dogs. The organs that herniate into the pleural cavity are determined by the location of the rupture. They are most commonly circumferential tears that occur at the attachment of the diaphragm and rib. Is these cases, the organs that herniate may include the liver, small intestine, stomach, spleen, omentum, and/or uterus. Dorsal tears are uncommon, and may cause a kidney to herniate into the thorax. Symptoms include difficulty breathing, vomiting, collapse, and an absence of palpable organs in the abdomen. Symptoms can worsen quickly and be lethal, especially in the case of severe bleeding, bruised heart, or strangulation of herniated intestine. It is also possible that there may only be subtle signs, and the condition is only incidentally detected months to years after the injury during a medical scan. [15]

See also

Related Research Articles

<span class="mw-page-title-main">Hernia</span> Abnormal exit of tissues or organs from the cavity they usually reside in

A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the intestinal tract, referring to the retraction of the intestine from the extra-embryonal navel coelom into the abdomen in the healthy embryo at about 7½ weeks.

<span class="mw-page-title-main">Thorax</span> Frontal part of an animals body, between its head and abdomen

The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the creature's body, each of which is in turn composed of multiple segments.

<span class="mw-page-title-main">Thoracic diaphragm</span> Sheet of internal skeletal muscle

The thoracic diaphragm, or simply the diaphragm, is a sheet of internal skeletal muscle in humans and other mammals that extends across the bottom of the thoracic cavity. The diaphragm is the most important muscle of respiration, and separates the thoracic cavity, containing the heart and lungs, from the abdominal cavity: as the diaphragm contracts, the volume of the thoracic cavity increases, creating a negative pressure there, which draws air into the lungs. Its high oxygen consumption is noted by the many mitochondria and capillaries present; more than in any other skeletal muscle.

<span class="mw-page-title-main">Congenital diaphragmatic hernia</span> Medical condition

Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm. The most common type of CDH is a Bochdalek hernia; other types include Morgagni hernia, diaphragm eventration and central tendon defects of the diaphragm. Malformation of the diaphragm allows the abdominal organs to push into the chest cavity, hindering proper lung formation.

<span class="mw-page-title-main">Gastrointestinal perforation</span> Medical condition

Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.

<span class="mw-page-title-main">Hemothorax</span> Blood accumulation in the pleural cavity

A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to Pneumothorax, or rarely in association with other conditions.

<span class="mw-page-title-main">Abdomen</span> Part of the body between the chest and pelvis

The abdomen is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso. The area occupied by the abdomen is called the abdominal cavity. In arthropods, it is the posterior tagma of the body; it follows the thorax or cephalothorax.

<span class="mw-page-title-main">Pneumoperitoneum</span> Medical condition

Pneumoperitoneum is pneumatosis in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal organ, generally from a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma. A perforated appendix seldom causes a pneumoperitoneum.

<span class="mw-page-title-main">Diaphragmatic hernia</span> Medical condition

Diaphragmatic hernia is a defect or hole in the diaphragm that allows the abdominal contents to move into the chest cavity. Treatment is usually surgical.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, sports-related injuries, and are notably common among the elderly who experience falls.

<span class="mw-page-title-main">Chest injury</span> Medical condition

A chest injury, also known as chest trauma, is any form of physical injury to the chest including the ribs, heart and lungs. Chest injuries account for 25% of all deaths from traumatic injury. Typically chest injuries are caused by blunt mechanisms such as direct, indirect, compression, contusion, deceleration, or blasts caused by motor vehicle collisions or penetrating mechanisms such as stabbings.

Hemoperitoneum is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemoperitoneum is generally classified as a surgical emergency; in most cases, urgent laparotomy is needed to identify and control the source of the bleeding. In selected cases, careful observation may be permissible. The abdominal cavity is highly distensible and may easily hold greater than five liters of blood, or more than the entire circulating blood volume for an average-sized individual. Therefore, large-scale or rapid blood loss into the abdomen will reliably induce hemorrhagic shock and, if untreated, may rapidly lead to death.

<span class="mw-page-title-main">Bochdalek hernia</span> Medical condition

Bochdalek hernia is one of two forms of a congenital diaphragmatic hernia, the other form being Morgagni hernia. A Bochdalek hernia is a congenital abnormality in which an opening exists in the infant's diaphragm, allowing normally intra-abdominal organs to enter into the thoracic cavity. In the majority of people, the affected lung will be deformed, and the resulting lung compression can be life-threatening. Bochdalek hernias occur more commonly on the posterior left side.

<span class="mw-page-title-main">Penetrating trauma</span> Type of injury

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.

<span class="mw-page-title-main">Pulmonary laceration</span> Medical condition

A pulmonary laceration is a chest injury in which lung tissue is torn or cut. An injury that is potentially more serious than pulmonary contusion, pulmonary laceration involves disruption of the architecture of the lung, while pulmonary contusion does not. Pulmonary laceration is commonly caused by penetrating trauma but may also result from forces involved in blunt trauma such as shear stress. A cavity filled with blood, air, or both can form. The injury is diagnosed when collections of air or fluid are found on a CT scan of the chest. Surgery may be required to stitch the laceration, to drain blood, or even to remove injured parts of the lung. The injury commonly heals quickly with few problems if it is given proper treatment; however it may be associated with scarring of the lung or other complications.

<span class="mw-page-title-main">Subcutaneous emphysema</span> Medical condition

Subcutaneous emphysema occurs when gas or air accumulates and seeps under the skin, where normally no gas should be present. Subcutaneous refers to the subcutaneous tissue, and emphysema refers to trapped air pockets. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs around the upper torso, such as on the chest, neck, face, axillae and arms, where it is able to travel with little resistance along the loose connective tissue within the superficial fascia. Subcutaneous emphysema has a characteristic crackling-feel to the touch, a sensation that has been described as similar to touching warm Rice Krispies. This sensation of air under the skin is known as subcutaneous crepitation, a form of crepitus.

<span class="mw-page-title-main">Tracheobronchial injury</span> Damage to the tracheobronchial tree

Tracheobronchial injury is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.

<span class="mw-page-title-main">Abdominal trauma</span> Medical condition

Abdominal trauma is an injury to the abdomen. Signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen. Complications may include blood loss and infection.

An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the staging of some cancers.

Splenosis is the result of spleen tissue breaking off the main organ and implanting at another site inside the body. This is called heterotopic autotransplantation of the spleen. It most commonly occurs as a result of traumatic splenic rupture or abdominal surgery. Depending on the location of the spleen, the new piece usually implants in another part of the abdominal cavity. Single case reports also describe splenosis in the thoracic cavity, in subcutaneous tissue, in the liver or in the cranial cavity. Splenosis must be distinguished from the presence of additional spleens, which are innate and are the result of differences in embryological development. Additionally, splenosis must be differentiated from malignant tumors which may look similar when imaged.

References

  1. ↑ Hariharan D, Singhal R, Kinra S, Chilton A (2006). "Post traumatic intra thoracic spleen presenting with upper GI bleed! A case report". BMC Gastroenterol. 6: 38. doi: 10.1186/1471-230X-6-38 . PMC   1687187 . PMID   17132174.
  2. 1 2 3 4 Furák J, Athanassiadi K (February 2019). "Diaphragm and transdiaphragmatic injuries". Journal of Thoracic Disease. 11 (Suppl 2): S152–S157. doi: 10.21037/jtd.2018.10.76 . ISSN   2072-1439. PMC   6389556 . PMID   30906579.
  3. 1 2 3 4 Mason RJ, Slutsky A, Murray JF, Nadel JA, Gotway MB (2015-03-17). Murray & Nadel's Textbook of Respiratory Medicine E-Book. Elsevier Health Sciences. pp. 1622–1623. ISBN   978-0-323-26193-7.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Karmy-Jones R, Jurkovich GJ (March 2004). "Blunt chest trauma". Current Problems in Surgery. 41 (3): 348–353. doi:10.1016/j.cpsurg.2003.12.004. PMID   15097979. 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.
  5. 1 2 3 4 5 6 McGillicuddy D, Rosen P (August 2007). "Diagnostic dilemmas and current controversies in blunt chest trauma". Emerg Med Clin North Am. 25 (3): 695–711, viii–ix. doi:10.1016/j.emc.2007.06.004. PMID   17826213.
  6. 1 2 3 4 5 6 7 8 9 10 11 12 13 Scharff JR, Naunheim KS (February 2007). "Traumatic diaphragmatic injuries". Thorac Surg Clin. 17 (1): 81–5. doi:10.1016/j.thorsurg.2007.03.006. PMID   17650700.
  7. 1 2 3 4 5 Weyant MJ, Fullerton DA (2008). "Blunt thoracic trauma". Seminars in Thoracic and Cardiovascular Surgery. 20 (1): 26–30. doi:10.1053/j.semtcvs.2008.01.002. PMID   18420123.
  8. ↑ Sliker CW (March 2006). "Imaging of diaphragm injuries". Radiol Clin North Am. 44 (2): 199–211, vii. doi:10.1016/j.rcl.2005.10.003. PMID   16500203.
  9. 1 2 3 4 5 6 Asensio JA, Petrone P, Demitriades D, commentary by Davis JW (2003). "Injury to the diaphragm". In Moore EE, Feliciano DV, Mattox KL (eds.). Trauma. Fifth Edition. McGraw-Hill Professional. pp. 613–616. ISBN   0-07-137069-2.
  10. 1 2 3 4 5 6 Fleisher GR, Ludwig S, Henretig FM, Ruddy RM, Silverman BK, eds. (2006). "Thoracic trauma". Textbook of Pediatric Emergency Medicine. Hagerstown, MD: Lippincott Williams & Wilkins. pp. 1446–7. ISBN   0-7817-5074-1.
  11. ↑ Berger D, Takala J (September 2018). "Determinants of systemic venous return and the impact of positive pressure ventilation". Annals of Translational Medicine. 6 (18): 5. doi: 10.21037/atm.2018.05.27 . ISSN   2305-5847. PMC   6186556 . PMID   30370277.
  12. 1 2 3 Gao R, Jia D, Zhao H, WeiWei Z, Yangming WF (September 2018). "A Diaphragmatic Hernia and Pericardial Rupture Caused by Blunt Injury of the Chest: A Case Review". Journal of Trauma Nursing. 25 (5): 323–326. doi:10.1097/JTN.0000000000000395. ISSN   1078-7496. PMC   6170143 . PMID   30216264.
  13. ↑ Desir A, Desir B (5 March 2012). "CT of Blunt Diaphragmatic Rupture". Radiographics. 32 (2): 477–496. doi:10.1148/rg.322115082. PMID   22411944 – via Radiological Society of North America.
  14. ↑ Desir A, Ghaye B (2012-03-01). "CT of Blunt Diaphragmatic Rupture". RadioGraphics. 32 (2): 477–498. doi:10.1148/rg.322115082. ISSN   0271-5333. PMID   22411944.
  15. ↑ Spattini G, Rossi F, Vignoli M, Lamb CR (2003). "Use of Ultrasound to Diagnose Diaphragmatic Rupture in Dogs and Cats". Veterinary Radiology & Ultrasound. 44 (2): 226–230. doi:10.1111/j.1740-8261.2003.tb01276.x. ISSN   1740-8261. PMID   12718361.
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