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CASE STUDYDr Saleem Muhammad ManshaPGR Alnoor Diagnostic Centre

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

CT SCAN (Coronal view)

USG

From Imaging we can ConcludeElevated Left hemi diaphragmNo shift of mediastinum or hilar displacementNo mass in lung No volume loss in lung No collapse of lungNo evidence of consolidationDiaphragm surface is smooth No mass seen in or below the diaphragm No visceromegaly No ascites

The most probable diagnosis in our case is Diaphragmatic eventration .

Diaphragmatic EventrationNormal 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 previouslyTotal or PartialTotal eventration mostly on Left side & partial mostly on Right side

Causes and differential for elevated hemidiaphragm

Causes above DiaphragmPhrenic Nerve PalsyPulmonary collapseSubpulmonic effusionInflammatory infiltrate in lungsPulmonary Infarction Pleural disease (Haemothorax , empyema )Hemiplegia

Diaphragmatic CausesEventrationDiaphragmatic herniasDiaphragmatic tumors Diaphragmatic trauma

Causes Below DiaphragmGaseous distension of stomach and colon Subphrenic abscessSubphrenic mass Massive ascites

Causes Above Diaphragm

Phrenic Nerve PalsyMass in Left upper zone compressing Left Phrenic NerveRaised Left Hemi DiaphragmNo movement of diaphragm possible

Left Lower Lobe Collapse (PA View)

Raised Left hemi diaphragmLoss of volume on left sideIpsilateral shift of heartDouble opacity behind heartSilhouette sign

Subpulmonic Effusion

Raised hemidiaphragmLateralization of diaphragm apex

Acute Pneumonia

Raised Right hemi diaphragm due to lower lobe infiltrate

HaemothoraxH/O Trauma

Diaphragmatic Causes

Bochdalak HerniaMostly on leftPosterior aspect of diaphragmMay contain Retroperitoneal fat , kidney and spleen

Morgagni HerniaCXRCT

Primary Malignant Tumor of Diaphragm

Trauma

Causes Below Diaphragm

Distended Stomach

Liver Mass

Post surgical Subphrenic AbscessCXR

CT(Axial view)

Massive AscitesRight hemidiaphragm is elevated

Take Home MessageAll 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 .