1.IMAGING MODALITIES OF DIAPHRAGM DR. ARIF KHAN S

2. DIAPHRAGM (S) Diaphragm : Seperation Thoracic Diaphragm Pelvic Diaphragm Urogenital Diaphragm 3. THORACIC DIAPHRAGM (ANATOMY) Dome shaped Muscular fibres : orgin Sternal below XIPHOlD process , Costal - Inner surface of costal cartilages of 6th ribs , lumbar - Aponurotic arches of lumbar vertebrae 4. lumbocostal arches : 2 pairs Medial lumbocostal arches : tendinous arch covering psoas major; continuous medially with left crura ; attached to L2 vertebral body and in the front of the transverse process of L1 and L2 Lateral lumbocostal arches : covers quadratus lumborum; attached medially to the L1 transverse process and attached laterally to the tip of the 12th rib Crurae : Right and Left ; Blends to the Anterior longitudinal ligament of vertebrae CENTRAL TENDON: Strong aponeurosis. below pericardium 5. Aortic Hiatus (T12) Oesophageal Hiatus (T10 ) Vena caval foramen (T8) Lesser apertures BLOOD SUPPLY At 1.Costal margins lower 5 intercostal A. 2. Abdominal surface Rt & Lt Inf.Phrenic A. 3. Superior phrenic A. And Musculophrenic A NERVE SUPPLY Rt and Left phrenic N. & inter costal N. 6. NORMAL CHEST X-RAY 7. Normal Diaphragm is 2-3 mm thick Which is normally not measurable In right side unless there is free peritoneal gas or bowel loop separating the liver from diaphragm. In the left side the combined stomach wall and diaphragm form linear density of 5-8 mm thick. Thickening in most cases are normal. Pathological thickening is seen in 1. Tumors of diaphragm; stomach & pleura 2. Subpulmonary fluid 3. Diaphragmatic humps 4. Abdominal lesions : splenomegaly, Hepatomegaly Sub-phrenic abscess 8. NORMAL VARIATIONS Scalloping: Rt side common; Muscle slips Dipahragmatic humps and Dromedary hump Eventration Accessory Diaphragm 9. DIAPHRAGM (PHYSIOLOGY) Function : Seperation between Thoracic and Abdominal cavities. Aid in Respiration as Chief Inspiratory muscle Two components : non contractile central tendon ;contracting muscle fibres Contraction of muscles induce intra-pleural pressure cause air to be sucked in the lungs Contributes 3/4th of inspiratory volumes at the vital capacity. Normal movement is 3-5 cm Abnormal movement or reduced movement is seen in paralysis of diaphragm Movement of diaphragm can be assessed using USG or Flouroscopy 10. PATHOLOGIES OF DIAPHRAGM 11. DIAPHRAGMATIC PARALYSIS Due to injury to Phrenic nerve. Unilateral or Bilateral Increase load can cause respiratory failure Assosciated with conditions like : Spinal cord transection, Multiple sclerosis, Amyotrophic lateral Sclerosis, Cervical spondylosis GBS, Isolated Phrenic Nerve dysfunction: Compression by tumor, Cardiac surgery cold injury, blunt trauma, etc. 12. Chest radiograph show elevated hemidiaphragm and Atelectasis of lung Flouroscopy aid s in clear visualization of the movement of the diaphragm Sniff Test: Parodoxical Elevation of diaphragm in inspiration Other tests : PFT, EMG and phrenic nerve stimulation USG 13. DIAPHRAGMATIC MOVEMENT ASSESSEMENT THORACIC ULTRASOUND: Principles: Changes in diaphragm thickness during contraction. (chronically paralyzed diaphragm is atrophic and does not thicken during inspiration ) Should be assessed in two areas Liver at the Right and Spleen window on the left Low frequency probes are used. 14. POST PROCEDURE INDUCED DIAPHRAGMATIC PARALYSIS (TRANSIENT TYPE) 15. FIG 1 FIG 2 16. RUPTURE OF DIAPHRAGM Traumatic diaphragmatic injuries occur in 0.8%8% of patients who sustain blunt trauma. Up to 90% of diaphragmatic ruptures from blunt trauma occur in young men after motor vehicle accidents Both bilateral tears and extension of tears into the central tendon are uncommon. They are reported in 2%6% of patients with diaphragmatic injury. Mechanisms of injuries include a lateral impact, and shears the diaphragm, and a direct frontal impact 17. Most ruptures are longer than 10 cm and occur at the posterolateral aspect of the hemidiaphragm between the lumbar and intercostal attachments and spread in a radial direction Penetrating injuries such as gunshot wounds or stab injuries are more random Sites of injuries. Drawing shows radial (A), transverse (B), and central (C) ruptures and a peripheral detachment (D). Radial tears appear to be the most frequently found injury at surgery, whereas peripheral detachments are the least frequent. 18. ASSOSCIATED INJURIES Common : pelvic fractures (40%55%), splenic injuries (60%), and renal injuries High frequency of liver injuries, which are more frequently associated with right than with left diaphragmatic tears Thoracic injuries : pneumohemothoraces and rib fractures are seen in 90% of patients. Aortic thoracic injuries are reported in 5% of patients 19. DIAPHRAGM INJURY (IMAGING) Chest X-ray : (a) intrathoracic herniation of a hollow viscus (stomach, colon, small bowel) with or without focal constriction of the viscus at the site of the tear (collar sign) (b) visualization of a nasogastric tube above the hemidiaphragm on the left side Findings suggestive of hemidiaphragmatic rupture include elevation of the hemidiaphragm, distortion or obliteration of the outline of the hemidiaphragm, and contralateral shift of the mediastinum 20. CT CHEST: Helical CT has proved to be more valuable in the detection of diaphragmatic injuries with a sensitivity of 71% Findings : 1. Direct discontinuity of the hemidiaphragm; sensitivity 73%, specificity 90%. 2. Intrathoracic herniation of abdominal contents; sensitivity 55%, specificity 100%. 3. The collar sign: sensitivity 36% with conventional CT 63% with helical CT. On the right side, the collar sign can appear as a focal indentation of the liver, a subtle sign easily overlooked 4. The dependent viscera sign: sensitivity: 100%: left- sided 83%: right-sided when a patient with a ruptured diaphragm lies supine at CT examination, the herniated viscera (bowel or solid organs) are no longer supported posteriorly by the injured diaphragm and fall to a dependent position against the posterior ribs 21. CONGENITAL DIAPHRAGMATIC HERNIA Diaphragmatic hernias include Bochdalek (posterolateral), Morgagni (retrosternal), and hiatal hernias Antenatal USG scan can diagnose all types earlier USG can in aid in determining the survivability of the foetus. Congenital diaphragmatic hernia (CDH) is a major surgical emergency in newborns. The key to survival lies in prompt diagnosis and treatment Pulmonary hypertension and Pulmonary hypoplasia are complications 22. MORGAGNIS HERNIA Anterior defect of the diaphragm Retrosternal, or parasternal hernia herniation through the foramina of Morgagni Associated pericardial defect , pleural and or pericardial effusion may b seen Contents : the liver, spleen, and omentum D/d s Thymoma, Rt middle lobe collapse, hydatid cyst, fibrous tumor of the pleura Cardiophrenic angle lesions: lymphadenopathy : metastasis, lymphoma, reactional Pericardial Cyst ; pericardial lipomatosis 23. MORGAGNI HERNIA Morgagni hernia in a 2-year-old child. Lateral chest radiograph shows herniation of a bowel loop (arrows) in a classic location through an anteromedial defect. Anterior herniation of bowel loops on a lateral chest radiograph is the typical finding. Other herniated viscera include the liver, spleen, and omentum. 24. FIG 1 FIG 2 25. FIG 1 ` FIG 2 26. FIG 1 FIG 2 27. BOCHDALEK HERNIA Posterior aspect defect in the posterior attachment of the diaphragm when there is a failure of pleuroperitoneal membrane closure in utero most frequently left sided. 28. BOCHDALEK HERNIA Frontal radiograph of the chest in a newborn shows herniation of bowel loops into the left hemithorax with displacement of the heart to the right, findings consistent with left Bochdalek hernia. The nasogastric tube (arrows) in the left hemithorax indicates the intrathoracic stomach. 29. HIATUS HERNIA A .K.a. oesophageal hiatal hernia herniation of stomach through the oesophageal hiatus of the diaphragm Types 1. Sliding 2. roling (para-oesophageal) Content : always Stomach ; rarely with bowel loops (if the defect is large enough) D/ds Lung abscess (Retro- cardiac) Empyema , epiphrenic oesophageal diverticulum 30. FIG 1 FIG 2 31. FIG 1 FIG 2 32. FIG 1 FIG 2 33. CONGENITAL DIAPHRAGMATIC EVENTRATION Abnormal elevation of part or all of an otherwise intact hemidiaphragm into the chest cavity is termed eventration. CAUSES congenital absence of muscle fibers focal dyskinesia and weakness from ischemia, infarct, neuromuscular dysfunction. The anteromedial aspect of the right side D/Ds Morgagni hernia, pericardial cyst, paraesophageal hernia, bronchogenic cyst, and tumor. 34. Focal eventration (arrow) at the anteromedial aspect of the right hemidiaphragm. The eventration contains part of the liver. 35. Eventration (arrow) at the left hemidiaphragm at seen at birth. Complete eventration of a hemidiaphragm is more common in males and typically occurs on the left side. 36. TUMORS Diaphragmatic tumors may be divided : (i) primary benign neoplasms; (2) primary malignant neoplasms; (3) secondary malignant neoplasms; (4) cysts; (5) inflammatory lesions (6) endometriosis. 37. PRIMARY BENIGN NEOPLASMS; Can arise from any of the normal tissue components . Eg: Lipomas, fibromas, angiofi bromas, neurofibromas and neurilemmomas are common; Adrenal cortical adenoma, liver cell adenoma, chondroma, hamartorna and mesothelioma are rarer Diagnosed mostly post mortem biopsy, X-ray appearance as irregularity in diaphragm 38. PRIMARY MALIGNANT NEOPLASMS Majority are fibrous tissue origin. Eg; (fibrosarcoma, fibro-myo-sarcoma, fibro- angio-endothelioma) or undifferentiated sarcomas. mixed cell sarcoma, myosarcoma, rhabdomyosarcoma, Of the reported primary tumors of the diaphragm, malignant neoplasms predominate in a ratio of about 60 :40. 39. LEIOMYOSARCOMA 40. SECONADARY MALIGNANT NEOPLASMS Secondary malignant neoplasms of the diaphragm may he due to direct invasion from adjacent lesions or metastatic spread OR through vascular channels. Resembles benign tumours radiogrpahically. Blood born mets are rare Direct spread from lver ,lungs (incl pleura), stomach, kidneys adrenaals are seen ; Others include chondro sarcoma , Hodgkins disease 41. SECONDARY DUE TO PRIMARY OVARIAN CARCINOMA 42. SPLENIC FLEXURE COLON CARCINOMA INVADING THRU DIAPHRAGM 43. FIG 1 FIG 2 44. SPOTTERS 45. THANK YOU