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eComment: Spontaneous or effort diaphragmatic rupture

National Cardiothoracic Centre, Korle Bu Teaching Hospital, PO Box KB 846, Korle Bu, Accra, Ghana

Diaphragmatic rupture during labour, two years after an intra-oesophageal rupture of a bronchogenic cyst treated by an omental wrapping

The entity referred to by Rubin and colleagues [1] and commonly termed spontaneous diaphragmatic rupture in the literature is probably best described as effort diaphragmatic rupture. Spontaneous in this sense connotes rupture of the diaphragm without antecedent factors which is clearly not the case in this patient or in the cases reported in the literature. Together with others [2, 3], we are of the opinion that the use of the term spontaneous in this regard is a misnomer and diverts attention from the clinical recognition of antecedent factors that may raise the clinician's index of suspicion.

Effort rupture represents 1% of all diaphragmatic ruptures and may affect the left or right hemidiaphragm or occur bilaterally [3]. Although adults are the most often affected, the condition has been reported in children as well [4]. Antecedents so far described include violent coughing, excessive retching or vomiting, parturition, straining at stool and strenuous physical or athletic events. The common denominator in all these is a violent Valsalva maneuver causing a sudden surge in the abdomino-thoracic pressure gradient which is believed to be the primary underlying mechanism responsible for the diaphragmatic rupture. This same surge in pressure gradient (but of a greater magnitude) is thought to be responsible for blunt traumatic diaphragmatic rupture. Relatively less pressure is required to disrupt the diaphragm in effort rupture. This predisposition may be due to pre-existing congenital lesions (fenestrations, Ehlers-Danlos syndrome) or acquired diaphragmatic weakness (previous phrenotomy [1], emphysema and malnutrition).

Diagnosis of effort rupture is often confounded by a low clinical and radiological index of suspicion and non-specific symptomatology. Affected patients often report sudden onset of epigastric and or lower chest pain after an event involving a Valsalva maneuver. With left-sided involvement, nausea, vomiting and dyspnea may follow as intra-abdominal contents herniate into the left hemithorax. Right-sided involvement is more difficult to detect.

Awareness of the condition and recognition of the presence of the various antecedents is the first step towards diagnosis. The diagnostic yield of the various imaging tools is dependent on the hemidiaphragm involved and has been commented on elsewhere [5]. Surgical repair is the treatment of choice. Delayed diagnosis and comorbidities portend a poor outcome for patients with effort diaphragmatic rupture.

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1. Rubin S, Sandu S, Durand E, Baehrel B. Diaphragmatic rupture during labour, two years after an intra-oesophageal rupture of a bronchogenic cyst treated by an omental wrapping. Interact CardioVasc Thorac Surg 2009;9:374–376.[Abstract/Free Full Text]
2. Matsevych OY. Blunt diaphragmatic rupture: four year's experience. Hernia 2008;12:73–78.[CrossRef][Medline]
3. El Nakadi B, Vanderhoeft P. Effort rupture of the diaphragm. Thorax 1990;45:715.[Abstract/Free Full Text]
4. Akbar A, Parikh DH, Alton H, Clarke JR, Weller PH, Green SH. Spontaneous rupture of the diaphragm. Arch Dis Child 1999;81:341–342.[Abstract/Free Full Text]
5. Edwin F. eComment: a practical approach for imaging of diaphragmatic injury. Interact CardioVasc Thorac Surg 2009;9:374–376.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Frank Edwin Mark M. Tettey Lawrence Sereboe Kwabena Frimpong-Boateng Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Edwin, F. Articles by Frimpong-Boateng, K. Search for Related Content PubMed PubMed Citation Articles by Edwin, F. Articles by Frimpong-Boateng, K. Related Collections Related Article