Clinical History
The young female patient with haemodynamic instability was involved in a high-speed motor-vehicle accident.
Imaging Findings
The Computed Tomography (CT) scan, performed on an emergency basis both with and without contrast media injection, revealed bilateral pulmonary contusions, small left pneumothorax and left diaphragmatic rupture with combined intrathoracic gastric and left liver lobe herniation (Fig. 1). Abdominal CT findings included splenic rupture of the upper pole (Fig. 2), multiple pelvic fractures (Fig. 3), active bleeding from mesenteric vessels (Fig. 4), and an excessive amount of intraperitoneal free fluid. Additionally, CT findings of shock bowel were present, including thickened small bowel loops with enhancing walls and collapsed inferior vena cava (I.V.C) (Fig. 5).
Discussion
Diaphragmatic rupture is a tear of the diaphragm as a result of blunt abdominal or lower thoracic trauma. It occurs in 0.8 – 8% of patients involved in motor-vehicle collisions, most often young men, and has a high mortality risk (14 – 50%) [1, 2]. Most ruptures are long enough (more than 10 cm) and occur at the posterolateral aspect of each hemidiaphragm. The involvement of the left hemidiaphragm is more frequent, probably because of the liver’s buffering effect on the right side, resulting in stomach being the most commonly herniated organ, followed by bowel (most often small bowel), spleen and finally liver [3]. Pelvic fractures and splenic rupture constitute an often encountered finding in patients with post-traumatic diaphragmatic tear (40% and 25% of cases respectively) [4]. Clinical imaging includes dyspnoea, chest pain, abdominal pain and vomiting. Failure to identify this abnormality may lead to severe complications, such as cardiovascular-respiratory insufficiency, bowel strangulation and ischaemia [5]. Since the clinical diagnosis of post-traumatic diaphragmatic tear is often missed (up to 65% of patients), imaging evaluation is considered to be essential, with CT considered as the gold standard imaging examination. Some characteristic CT findings of diaphragmatic rupture include: a) diaphragm discontinuity, b) intrathoracic herniation of abdominal content, c) focal diaphragmatic thickening at the site of the tear, d) the ‘collar sign’: a waist-like constriction of the herniating organ (stomach and colon most commonly on the left side and liver on the right side) (Fig. 6), e) the ‘dependent viscera’ sign: in the supine position, the herniated viscera fall to a dependent position against the posterior ribs (Fig. 1) and f) accompanying haemothorax or haemoperitoneum [1, 2]. In order to make the final diagnosis, one should exclude congenital conditions such as Bochdalek hernia (posterior diaphragmatic hernia, usually left-sided, through which retroperitoneal fat, spleen or left kidney may prolapse) and Morgagni hernia (anterior, usually right-sided diaphragmatic hernia, which most often contains omental fat, transverse colon or liver), or other pathological conditions such as diaphragmatic eventration (abnormal segmental elevation of the diaphragmatic dome), where no diaphragmatic rupture exists, however.
Differential Diagnosis List
Multitrauma patient with left diaphragmatic tear resulting in gastric-hepatic herniation.
Bochdalek hernia
Morgagni hernia
Diaphragmatic eventration
Final Diagnosis
Multitrauma patient with left diaphragmatic tear resulting in gastric-hepatic herniation.
