What is Diaphragm Rupture?
The diaphragm is a flat, curved muscle that splits the chest from the stomach area. Injuries to the diaphragm are quite rare, accounting for less than 1% of all trauma injuries. These injuries are generally linked to severe trauma due to the high rate of related injuries. It’s more common for these injuries to occur because of penetrating trauma, like a stab wound, rather than blunt force. Notably, while significant injuries to the diaphragm are usually easily detectable, other injuries to the diaphragm may not be as evident. Therefore, to prevent missing this serious diagnosis, a high level of concern is required.
This injury, if not diagnosed, could lead to the displacement and compression of abdominal organs into the chest due to an unrepaired hole in the diaphragm. A robust understanding of the body’s structure, related injuries, and potential issues in diagnostic testing will aid in diagnosing this surgical problem.
What Causes Diaphragm Rupture?
Damage to the diaphragm can happen because of either sharp or blunt trauma. Sharp trauma, like a stab wound, gunshot wound, or impalement, directly injures the diaphragm and accounts for about two-thirds of all cases. These types of injuries often lead to smaller, one-sided damage, which can be missed during the first check-up.
The rest of the cases, about one-third, are due to blunt trauma, most commonly caused by car crashes. Falls and crush injuries are other common causes. Unlike sharp trauma, blunt trauma can cause larger rips in the diaphragm, and almost one-third of these can occur on both sides.
Risk Factors and Frequency for Diaphragm Rupture
Diaphragmatic injury, a type of trauma, is more frequently seen in men. The typical age for patients with non-penetrating injuries is around 44 years, while for those with penetrating injuries, it is approximately 31 years. People with non-penetrating injuries also tend to have more severe injuries. More than half of patients with this kind of trauma have other significant injuries as well. The death rate varies depending on the type and severity of the injury; it’s around 25% for all patients diagnosed with a diaphragmatic injury. Particularly, patients with non-penetrating injuries have the highest death rate due to associated injuries. Around 20% of patients die due to delayed symptoms from previous penetrating trauma leading to strangulation of bowel contents. It is important to note that small injuries to the diaphragm might be missed resulting in the true frequency of diaphragmatic injuries being unknown. However, the National Trauma Data Bank estimates it to be around 0.5%. The injury rate has been observed to increase recently, which could be due to improved early care in trauma, better detection of injuries, and greater survival rates in patients with severe injuries.
Signs and Symptoms of Diaphragm Rupture
Diaphragmatic injuries can lead to a wide range of symptoms, usually depending on the cause of the injury. Since the diaphragm is vital for breathing, people with this kind of injury may have trouble breathing. Usually, diaphragmatic injuries are spotted while doctors are examining and treating other injuries in the patient. A physical check-up can often reveal signs of these injuries. For instance, doctors may notice abnormal heart or lung placement. In some instances, if the abdominal organs have moved up to the chest cavity, doctors may hear stomach noises in the chest. It’s particularly important to look for these signs in people who have experienced penetrating trauma to certain areas. However, it’s also true that less than half of such injuries are identified before surgery. As such, the doctor has to be quite alert to the possibility of a diaphragmatic injury.
The doctor should examine the patient’s airway, breathing, circulation, disability and exposure with particular attention to the neck and chest areas. Symptoms such as a shifted windpipe (trachea), missing breath sounds or uneven chest expansion might indicate a diaphragmatic injury.
It’s worth noting that in most cases, the diagnosis might not be made prior to surgery and in 10-50% of patients, the diagnosis might be delayed for several days or weeks. When patients come in late, they typically show signs of organ or bowel herniation (displacement) into the chest cavity. Serious complications such as strangulation of the herniated part, inability to move it back and even pressure on the heart have been reported in patients showing late symptoms.
Testing for Diaphragm Rupture
If doctors suspect a certain digestive disorder, they might proceed with a chest X-ray. This type of imaging can sometimes reveal whether there is an issue, such as a tube from stomach getting twisted and landing in the chest, or pieces of bowel substance inside it. However, in about 40% of instances, the X-ray might not show any signs of a problem. This is especially common in patients who have been placed on a ventilator, as the pressure given by ventilator can prevent bowel substances from entering the chest area. Sometimes, the only signs of a problem might be a raised diaphragm, or symptoms indicating that parts of the lung have shrunk, or fluid in the lung coverings.
Ultrasound is another tool doctors use when inspecting trauma patients. It helps to detect if there is fluid in the stomach, heart cover, or chest. If a doctor experienced in ultrasound is doing the procedure, they might be able to see a problem in the diaphragm. But if the ultrasound does not show anything, this does not mean there is no issue.
Some patients might need a CT scan, especially if their blood pressure and heart rate are stable. CT scans can be particularly useful in identifying injuries to the diaphragm. Advanced CT machines can detect even minor injuries with around 66.7% accuracy. However, most individuals with a penetrating injury still do not receive a correct diagnosis before an operation.
Other medical procedures like a thoracoscopy – where a small instrument with a camera is inserted into the body to look at the diaphragm – can be used when there’s suspicion of a diaphragm injury. If other injuries do not necessitate an operation, doctors might prefer this non-invasive method. Similarly, laparoscopy, which is another less invasive method involving a camera, has an 88% accuracy in telling if there’s an injury to the diaphragm, and nearly 100% accuracy in confirming such injuries.
Treatment Options for Diaphragm Rupture
In an emergency, the top priority is to evaluate the trauma patient and manage their airway, breathing, and circulation. Using an oral or nasal tube can also help in making a diagnosis, as well as lessen the pressure caused by stomach contents, which can prevent further injury. In some cases, a chest tube may be needed to treat related conditions like blood in the chest cavity or collapsed lungs. Since injuries to the diaphragm don’t heal on their own, surgery is usually necessary.
Surgery is required for all left-sided diaphragm injuries and for most on the right side. There may be a small number of right-sided injuries which could potentially be managed without surgery, though this carries the risk of a delayed rupture. With these patients, it’s important they understand that risk. The surgical approach often involves entering through the abdomen, particularly if other injuries are being treated at the same time. For less severe injuries, a less invasive procedure using a scope may be suitable.
The actual surgical repair is straightforward. After pushing back any tissue that had pushed through the tear, the diaphragm rupture is closed using strong, non-dissolvable stitches. A chest tube is typically left in place for several days after the operation to assist with healing.
What else can Diaphragm Rupture be?
- Collapsed lung (Pneumothorax)
- Abdominal injury, either blunt or penetrating
- Presence of air in the abdominal cavity (Pneumoperitoneum)
What to expect with Diaphragm Rupture
The outlook is generally positive for patients who receive immediate treatment. Early deaths usually result from related injuries. In rare instances, a condition called re-expansion pulmonary edema, a lung problem, can occur after a type of surgery called laparotomy. If the injury was near the phrenic nerve, there’s a chance that diaphragmatic paralysis, which affects breathing, could happen. However, this typically resolves over several months.
Possible Complications When Diagnosed with Diaphragm Rupture
There can be several complications that arise from certain medical conditions or procedures. These include:
- Bowel herniation, which is when the bowel protrudes into areas it shouldn’t
- Incarceration, or the trapping of the bowel
- Strangulation, which is when the blood supply to a part of the bowel gets cut off
- Tension pneumothorax (also known as a collapsed lung) or hemothorax (where blood collects between the chest wall and the lung)
- Pericardial tamponade, which is a serious condition where fluid builds up around the heart causing it to work less effectively