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eComment: A practical approach for imaging of diaphragmatic injury

National Cardiothoracic Centre, Korle Bu Teaching Hospital, P.O. Box KB 846, Korle Bu, Accra, Ghana

Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients

Al-Refaie and colleagues deserve commendation for their excellent paper [1]. Although blunt traumatic diaphragmatic rupture (BTDR) is not uncommon, its presence is frequently overlooked in the acute setting. The authors rightly state that the diagnosis begins with clinical suspicion. Imaging studies constitute the next step in diagnosis. However, each method of imaging has advantages and drawbacks according to the type of diaphragmatic rupture. The distinction should also be made between diaphragmatic laceration without visceral herniation and traumatic diaphragmatic hernia. While the recognition of visceral herniation is usually straightforward on imaging studies, diaphragmatic laceration without herniation is frequently more difficult to detect. Failure to appreciate these facts in the midst of associated injuries contributes to unrecognized BTDRs.

In their report, the authors indicate that intra-operative diagnosis was made in 17.4% of patients; the chest X-ray and chest CT made the diagnosis in the rest. There is no indication whether the CT used was conventional or helical. Conventional CT has a variable sensitivity of 14–61% in the diagnosis of diaphragmatic rupture [2] which is not very different from that for chest radiography for left-sided lesions. However, helical CT has a sensitivity of 71% (78% for left-sided injuries and 50% for right-sided injuries) [3].

The diagnostic efficacy of the chest X-ray for left-sided BTDR may be enhanced by a repeat examination after the passage of a radiopaque nasogastric tube or simple contrast studies of the upper gastro-intestinal tract. These simple techniques have been found to be more cost-effective in my institution for the evaluation of left-sided BTDR. Drawbacks of chest radiography include limited usefulness in right-sided BTDR and BTDR without visceral herniation. In addition, concurrent pulmonary abnormalities such as pleural effusion, pulmonary contusion and atelectasis can mimic or mask BTDR on chest radiographs [3]. The rate of missed diaphragmatic rupture on chest radiographs ranges from 12 to 66% [4].

In right-sided BTDR, the sensitivity of the plain chest X-ray may be as low as 17% [2]. The chest CT, preferably helical, is more useful in this regard. Because BTDR is rarely isolated, the CT is advantageous in the evaluation of associated injuries. Drawbacks of CT include false positive findings (asymptomatic Bochdalek defects and diaphragmatic eventration) [3] and relatively higher cost. Magnetic resonance imaging or laparoscopy may be used to evaluate the diaphragm for patients with clinical suspicion but an indeterminate diagnosis after chest radiography and spiral CT.

	References

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1. Al-Refaie RE, Awad E, Mokbel EM. Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients. Interact CardioVasc Thorac Surg 2009;9:45–49.[Abstract/Free Full Text]
2. Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR Am J Roentgenol 1991;156:51–57.[Abstract/Free Full Text]
3. Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG. Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics 2002;22; Spec No:S103–S116; discussion S116–S118.
4. Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Buchler MW. Missed diaphragmatic injuries and their long-term sequelae. J Trauma 1998;44:183–188.[Medline]

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