Routes of Transdiaphragmatic Migration from the Abdomen to the Chest

Approach to Acute Traumatic and Nontraumatic Diaphragmatic Abnormalities

Acute diaphragmatic abnormalities encompass a broad variety of relatively uncommon and underdiagnosed pathologic conditions, which can be subdivided into nontraumatic and traumatic entities. Nontraumatic abnormalities range from congenital hernia to spontaneous rupture, endometriosis-related disease, infection, paralysis, eventration, and thoracoabdominal fistula. Traumatic abnormalities comprise both blunt and penetrating injuries. Given the role of the diaphragm as the primary inspiratory muscle and the boundary dividing the thoracic and abdominal cavities, compromise to its integrity can yield devastating consequences. Yet, diagnosis can prove challenging, as symptoms may be vague and findings subtle. Imaging plays an essential role in investigation. Radiography is commonly used in emergency evaluation of a patient with a suspected thoracoabdominal process and may reveal evidence of diaphragmatic compromise, such as abdominal contents herniated into the thoracic cavity. CT is often superior, in particular when evaluating a trauma patient, as it allows rapid and more detailed evaluation and localization of pathologic conditions. Additional modalities including US, MRI, and scintigraphy may be required, depending on the clinical context. Developing a strong understanding of the acute pathologic conditions affecting the diaphragm and their characteristic imaging findings aids in efficient and accurate diagnosis. Additionally, understanding the appearance of diaphragmatic anatomy at imaging helps in differentiating acute pathologic conditions from normal variations. Ultimately, this knowledge guides management, which depends on the underlying cause, location, and severity of the abnormality, as well as patient factors. ©RSNA, 2024 Supplemental material is available for this article.

Empyema associated with peritoneal dialysis peritonitis

A 65-year-old woman on peritoneal dialysis (PD) was admitted due to abdominal pain with cloudy PD effluent. The white blood cell count in PD effluent was 5860/µL with 85% polymorphonuclear neutrophils. Therefore, she was clinically diagnosed with peritonitis. The cultures of PD effluent were negative. Initial abdominal computed tomography did not find suggest any intraabdominal pathology. The patient was treated with empirical intraperitoneal antibiotics. Because abdominal pain with cloudy PD effluent persisted, the PD catheter was removed eventually. The culture of the removed PD catheter grew Klebsiella pneumoniae. However, intermittent fever was noted over the following days and empyema developed approximately 2 weeks after PD catheter removal. The culture of pleural fluid also grew K. pneumoniae. Another computed tomography revealed multiple intraabdominal abscesses that was assumed to come from a complication of PD-associated peritonitis. We postulate that the empyema might be caused by transdiaphragmatic extension of the intraabdominal abscesses into the pleural space.

Case Series of MRI and CT Assessment of Acquired Hepato-Biliary and Pancreatic Transdiaphragmatic Fistulae

Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of abnormal communication between the liver and/or the biliary system and the thorax; while the pancreaticopleural fistula consists of abnormal communication between the pancreas and the thorax, the pleuro-biliary fistula represents the more common type. Clinical symptoms and laboratory findings are generally non-specific (e.g., thoracic and abdominal pain, dyspnea, cough, neutrophilia, elevated CPR, and bilirubin values) and initially, first-level investigations, such as chest RX and abdominal ultrasound, are generally inconclusive for the diagnosis. Contrast-enhanced CT represents the first two-level radiological imaging technique, usually performed to identify and evaluate the underlying pathology sustained by transdiaphragmatic fistulae, their complications, and the evaluation of the fistulous tract. When the CT remains inconclusive, other techniques such as MRI and MRCP can be performed. A prompt and accurate diagnosis is crucial because the recognition of fistulae and the precise definition of the fistulous tract have a major impact on the management acquisition process.

Lung abscess with chronic cough secondary to xanthogranulomatous pyelonephritis: A rare case report

RATIONALE

Xanthogranulomatous pyelonephritis (XGPN) is a form of chronic pyelonephritis caused by chronic calculus obstruction and bacterial infection, leading to the destruction of the renal parenchyma and calyces. Conservative treatment is usually not sufficient, and surgical intervention is still the main curative approach. XGPN with transdiaphragmatic extension and lung abscess formation is a rare condition.

PATIENT CONCERNS

We report a 64-year-old woman who presented with persistent productive cough.

DIAGNOSES

Lung abscess secondary to XPGN. Both nephrostomy urine and sputum cultures showed Proteus mirabilis infection with the same antibiotic sensitivity spectrum, but blood culture was negative.

INTERVENTIONS

Laparoscopic radical nephrectomy and prolonged antibiotic treatment.

OUTCOMES

The lung abscess and cough gradually resolved in 1 month after nephrectomy.

CONCLUSION

Lung abscess secondary to transdiaphragmatic extension of XGPN is rare but should be considered in patients with lower lung infections that are unresponsive to treatment, especially infections due to unusual respiratory pathogens such as P mirabilis.

Pleural empyema secondary to perforated diverticulosis due to biliary neoplasia infiltration

A long-term female smoker presented to the emergency department with cough, greenish mucus and dyspnoea, without fever. The patient also reported abdominal pain and significant weight loss in recent months. Laboratory tests showed leucocytosis with neutrophilia, lactic acidosis and a faint left lower lobe consolidation on chest X-ray, for which she was admitted to the pneumology department and started on broad-spectrum antibiotherapy. After 3 days of clinical stability, the patient deteriorated rapidly, with worsening of analytical parameters and coma. The patient died a few hours later. Given the rapid and unexplained evolution of the disease, a clinical autopsy was requested, which revealed a left pleural empyema caused by perforated diverticula by neoplastic infiltration of biliary origin.

Traumatic intrapericardial diaphragmatic hernia

Traumatic intrapericardial diaphragmatic hernias are very rare; they occur when the central tendon of the diaphragm ruptures, allowing abdominal viscera to herniate into the pericardial sac, causing life-threatening cardiac tamponade. Computed tomography imaging with multiplanar reconstruction is useful in evaluating such cases.

The Importance of the Posterolateral Area of the Diaphragm Muscle for Palpation and for the Treatment of Manual Osteopathic Medicine

The eupneic act in healthy subjects involves a coordinated combination of functional anatomy and neurological activation. Neurologically, a central pattern generator, the components of which are distributed between the brainstem and the spinal cord, are hypothesized to drive the process and are modeled mathematically. A functionally anatomical approach is easier to understand although just as complex. Osteopathic manipulative treatment (OMT) is part of osteopathic medicine, which has many manual techniques to approach the human body, trying to improve the patient's homeostatic response. The principle on which OMT is based is the stimulation of self-healing processes, researching the intrinsic physiological mechanisms of the person, taking into consideration not only the physical aspect, but also the emotional one and the context in which the patient lives. This article reviews how the diaphragm muscle moves, with a brief discussion on anatomy and the respiratory neural network. The goal is to highlight the critical issues of OMT on the correct positioning of the hands on the posterolateral area of the diaphragm around the diaphragm, trying to respect the existing scientific anatomical-physiological data, and laying a solid foundation for improving the data obtainable from future research. The correctness of the position of the operator's hands in this area allows a more effective palpatory perception and, consequently, a probably more incisive result on the respiratory function.