Опять диафрагмальная грыжа - SURGINET (какие КТ) !!

[Вячеслав Дмитриевич РЫНДИН]

Когда-то - 45 лет тому назад - я был просто убит рентгенологическим снимком лёгких нашего моряка, прибывшим из Индии.
Помчался к проф Марморштейну:
- Соломон Яковлевич, смотрите какие снимки!!!
- Как за за деньги...

Сегодня не удержался выразить свой восторг по поводу опять таки индийских снимков - делитесь со своими студентами!!

Dear friends - дорогие друзья

35 years obese male with vague symptoms of upper abdominal and lower chest dull ache pain mainly right side,
35 летний толстяк с блуждаюшими болями в верхних отделах живота и тупой болью в нижнем отделе грудной клетки больше справа...

...palpitation and giddiness off and on and heavyness in head for last 3-4 years. Appetite is good. No vomiting. No respiratory distress on heavy work. No cough.
... пальпитация и головокружение тяжесть в голове последние 3-4 года.. Аппетит хороший.. Рвоты нет.. При тяжёлой работе одышки нет.. Кашля нет..

Past history - Had left facial palsy and weakness in limb in 2004 ?CVA
Sudden loss of consciousness for brief period in 2004 and 2013
В прошлом - паралич лицевого нерва слева и слабость в конечностях в 2004 г Строк?

Known Diabetic on oral hypoglycemic drugs. well controlled
Диабетик.. Хорошо лечится оральными средствами..

CT Chest Few cuts attached
КТ грудной клетки - см ниже..

USG abdomen- No movements of left diaphragm
Bilateral Nephrolithiasis
УЗИ - неподвижность левого купола диафрагмы
Камни в почках

Endoscopy- Distal gastritis
Эндоскопия - дистальный гастрит

Physiacian wants surgery for eventration.
Терапевт требует хирургию по поводу эвентарации

My concerns - Мои сомнения -
1. All symptoms may not be related with eventration.
Все симптомы могут быть и не связанными с эвентерацией

2. Needs further workup-Cardiac and neurological as per his symptoms
Нуждается в более глубоком обследовании ССС и неврологиом

What is your opinion
Ваше мнение??
--
Dr.Banga
Gen.Surgeon
139 Old P.L.A.
Hisar(Haryana) Pin 125001
India
+919416042928(M)


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[Карлов Денис]

Релаксация левого купола диафрагмы.
Операция не показана.

[Вячеслав Дмитриевич РЫНДИН]

Правильно! Молодым нужно знать для ДД и для не вляпаться в операцию...

Diaphragmatic eventration
Dr Henry Knipe and Radswiki et al.
Diaphragmatic eventration refers to an abnormal contour of the diaphragmatic dome. It typically affects only a segment of the hemidiaphragm, compared to paralysis/weakness where the entire hemidiaphragm is typically affected. 
Pathology
Diaphragmatic eventration is congenital in nature and due to incomplete muscularisation of the diaphragm with a thin membranous sheet replacing normal diaphragmatic muscle.

***

Congenital diaphragmatic hernia (CDH) is a congenital malformation (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.
CDH is a life-threatening pathology in infants, and a major cause of death due to two complications: pulmonary hypoplasia and pulmonary hypertension.[1] Experts disagree on the relative importance of these two conditions, with some focusing on hypoplasia, others on hypertension.[2] Newborns with CDH often have severe respiratory distress which can be life-threatening unless treated appropriately.



Types of congenital diaphragmatic hernia[edit]
Bochdalek hernia[edit]
Main article: Bochdalek hernia
The Bochdalek hernia, also known as a postero-lateral diaphragmatic hernia, is the most common manifestation of CDH, accounting for more than 95% of cases. In this instance the diaphragm abnormality is characterized by a hole in the postero-lateral corner of the diaphragm which allows passage of the abdominal viscera into the chest cavity. The majority of Bochdalek hernias (80-85%) occur on the left side of the diaphragm, a large proportion of the remaining cases occur on the right side. To date, it carries a high mortality and an active area of clinical research.
Morgagni hernia[edit]


CT of the chest demonstrates a Morgagni hernia (red arrow)
This rare anterior defect of the diaphragm is variably referred to as Morgagni, retrosternal, or parasternal hernia. Accounting for approximately 2% of all CDH cases, it is characterized by herniation through the foramina of Morgagni which are located immediately adjacent and posterior to the xiphoid process of the sternum.[3]
Diaphragm eventration[edit]
The diagnosis of congenital diaphragmatic eventration is used when there is abnormal displacement (i.e. elevation) of part or all of an otherwise intact diaphragm into the chest cavity. This rare type of CDH occurs because in the region of eventration the diaphragm is thinner, allowing the abdominal viscera to protrude upwards.



Congenital diaphragmatic
eventration in an adult:
a diagnostic dilemma Mantoo S K, Mak K
ABSTRACT?Eventration of the diaphragm is a rare condition where the muscle is permanently elevated, but retains its continuity and attachments to the costal margins. It is seldom symptomatic and often requires no treatment, but may be confused with a traumatic rupture of the diaphragm. We present a 51-year-old man with previously- undiagnosed congenital eventration, mimicking traumatic rupture of the diaphragm. The role of clinical examination, imaging and diagnostic laparoscopy to differentiate between eventration and traumatic rupture of the diaphragm are discussed.
Keywords: congenital diaphragmatic eventration, diaphragmatic hernia, diaphragmatic rupture?Singapore Med J 2007; 48(5):e136–e137
INTRODUCTION
Eventration of the diaphragm is a condition where the muscle is permanently elevated, but retains its continuity and attachments to the costal margins.(1,2) It is rare, seldom symptomatic and often requires no treatment. However, this condition may be confused with a traumatic rupture of the diaphragm in a patient with trauma. Early recognition of traumatic rupture of the diaphragm is therefore of utmost importance.(3,4)
CASE REPORT
A 51-year-old man was admitted to the Department of Surgery following a fall from his motorcycle. He had sustained blunt trauma over the left side of his chest. He complained of pain in the left side of the chest, and had difficulty in breathing. Examination in the emergency department revealed tenderness and bruising over the left lateral chest wall, with reduced breath sounds and a resonant percussion note. Chest radiograph showed fractures of the left third, fourth and fifth ribs, with suspicion of pneumothorax (Fig. 1). Left intercostal tube drainage in the fifth space was done
Fig. 1 Anteroposterior chest radiograph shows a raised left hemidiaphragm.
Fig. 2 CT scanogram image shows an intact left diaphragm with bowel loops lying high in the left chest.
by the open method. The patient was monitored and referred to the surgical department.
The radiographs were reviewed and the patient was re-examined; this time bowel sounds were heard higher up to the level of the nipple on the left side. A traumatic rupture of the diaphragm was suspected. Since the patient was haemodynamically stable, urgent computed tomography (CT) scans of the abdomen and thorax were done (Figs. 2–4). The diaphragm was
Department of Surgery,?Alexandra Hospital, 378 Alexandra Road, Singapore 159964
Mantoo SK, MMed, MRCS, MS Registrar
Mak K, MMed, FRCS Consultant and Head
Correspondence to:
Dr Surendra Mantoo Tel: (65) 9664 5411 Fax: (65) 6379 3540 Email: skmantoo@ yahoo.co.in


Fig. 3 Axial CT image taken at mid-chest level shows bowel loops in the left chest.
Fig. 4 Axial CT image (lung window) taken at mid-chest level shows bowel loops in the left chest.
reported to be intact but bowel loops were found to be lying high up in the left chest. Radiographs and CT taken three years ago in another hospital were reviewed, which also confirmed the longstanding eventration of the left diaphragm. The patient was closely monitored. He recovered gradually and became asymptomatic. He is currently under follow-up.
DISCUSSION
Diaphragmatic eventration is rare, seldom symptomatic and often requires no treatment.(1,2) It often presents in the neonatal period with respiratory distress but is
also diagnosed in asymptomatic adults undergoing investigations for other reasons, or may be confused with traumatic rupture of the diaphragm. On the other hand, early diagnosis and repair of the traumatic diaphrag- matic hernia is important in order to avoid the potentially catastrophic risks of herniation, incarceration, and strangulation of the abdominal viscera.(3,4) A high index of suspicion, past history, previous and present imaging, and physical examination of the chest should aid in early and definitive diagnosis.
Multiple imaging modalities are available for the preoperative diagnosis of diaphragmatic injury. Chest radiographs are the initial and most commonly performed imaging study to evaluate the diaphragm after trauma. When chest radiographs are indeterminate, spiral CT with thin sections and reformatted images is the next study of choice. Magnetic resonance imaging is used to evaluate the diaphragm for patients with clinical suspicion but an indeterminate diagnosis after chest radiography and spiral CT.(5) Diagnostic laparoscopy should also be considered in difficult cases where imaging is not conclusive.(6) There is also a word of caution in our case, i.e. do not insert a chest tube without confirming the diagnosis, as it can be very dangerous for these patients.
We highlight the importance of a good physical examination, imaging and finally, a review of previous medical records in the management of these patients. Diagnostic laparoscopy can be an excellent tool in the evaluation of a stable patient with suspected diaphragmatic injury, which may be difficult to differentiate from diaphragmatic eventration on imaging.
REFERENCES
1. Donzeau-Gouge GP, Personne C, Lechien J, et al. [Eventration of the diaphragm in the adult - twenty cases] Ann Chir 1982; 36:87-90. French.
2. Gatzinsky P, Lepore V. Surgical treatment of a large eventration of the left diaphragm. Eur J Cardiothoracic Surg 1993; 7:271-4.
3. Reber PU, Schmied B, Seiler CA, et al. Missed diaphragmatic injuries and their long-term sequelae. J Trauma 1998; 44:183-8.
4. Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg 1995; 60:1444-9.
5. Shanmuganathan K, Killeen K, Mirvis SE, White CS. Imaging of diaphragmatic injuries. J Thorac Imaging 2000; 15:104-11.
6. Adamthwaite DN. Traumatic diaphragmatic hernia: a new indication for laparoscopy. Br J Surg 1984; 71:315.