Case Study: Diaphragm Eventration with differtials

Case study on Diaphragm Eventration with all differentials above and below diaphragm with cases.

1. ………

2. CASE STUDY Dr Saleem Muhammad Mansha PGR Alnoor Diagnostic Centre

3. Mr. Saber 50Y/M came for CT Chest with contrast at Alnoor Diagnostic centre on 03-08-2016 with h/o Fever 15 days Cough 4,5 days Intermittent SOB ( more on walking) No h/o Trauma , Anorexia , Weight loss

4. CT SCAN (Coronal view)

5. USG

6. From Imaging we can Conclude Elevated Left hemi diaphragm No shift of mediastinum or hilar displacement No mass in lung No volume loss in lung No collapse of lung No evidence of consolidation Diaphragm surface is smooth No mass seen in or below the diaphragm No visceromegaly No ascites

7. The most probable diagnosis in our case is Diaphragmatic eventration .

8. Diaphragmatic Eventration Normal Diaphragm is replaced by a thin layer of connective tissue and a few scattered muscle fibers Mostly congenital but can be acquired as many cases of surgically proven eventration had normal CXR previously Total or Partial Total eventration mostly on Left side & partial mostly on Right side

9. Causes and differential for elevated hemidiaphragm

10. Causes above Diaphragm Phrenic Nerve Palsy Pulmonary collapse Subpulmonic effusion Inflammatory infiltrate in lungs Pulmonary Infarction Pleural disease (Haemothorax , empyema ) Hemiplegia

11. Diaphragmatic Causes Eventration Diaphragmatic hernias Diaphragmatic tumors Diaphragmatic trauma

12. Causes Below Diaphragm Gaseous distension of stomach and colon Subphrenic abscess Subphrenic mass Massive ascites

13. Causes Above Diaphragm

14. Phrenic Nerve Palsy Mass in Left upper zone compressing Left Phrenic Nerve Raised Left Hemi Diaphragm No movement of diaphragm possible

15. Left Lower Lobe Collapse (PA View) Raised Left hemi diaphragm Loss of volume on left side Ipsilateral shift of heart Double opacity behind heart Silhouette sign

16. Subpulmonic E ffusion Raised hemidiaphragm Lateralization of diaphragm apex

17. Acute Pneumonia Raised Right hemi diaphragm due to lower lobe infiltrate

18. Haemothorax H/O Trauma

19. Diaphragmatic Causes

20. Bochdalak Hernia Mostly on left Posterior aspect of diaphragm May contain Retroperitoneal fat , kidney and spleen

21. Morgagni Hernia CXR CT

22. Primary Malignant Tumor of Diaphragm

23. Trauma

24. Causes Below Diaphragm

25. Distended Stomach

26. Liver Mass

27. Post surgical Subphrenic Abscess CXR CT(Axial view)

28. Massive Ascites Right hemidiaphragm is elevated

29. Take Home Message All cases of raised hemi diaphragm should be dealt with seriously to rule out causes above diaphragm , diaphragmatic causes and causes below the diaphragm. All modalities should be utilized for proper guidance and help of the patient .