Original article
Diaphragmatic Hernias: A Spectrum of Radiographic Appearances

https://doi.org/10.1067/j.cpradiol.2009.11.001Get rights and content

Diaphragmatic hernias are common, and although frequently incidental, recognition of both benign and life-threatening manifestations of diaphragmatic hernias is necessary to guide appropriate management. Congenital fetal diaphragmatic hernias, traumatic diaphragmatic rupture, and large symptomatic Bochdalek, Morgagni, and hiatal hernias are typically repaired surgically, while eventration, diaphragmatic slips, and small diaphragmatic hernias do not require intervention or imaging follow-up but should be recognized to avoid confusion with other diagnoses that require additional attention. This pictorial essay will explore the imaging findings and clinical characteristics of these entities.

Section snippets

Diaphragmatic Development and Anatomy

The embryologic development of the diaphragm remains incompletely understood. Between the 4th and 12th weeks of gestation, 4 elements converge to form the fetal diaphragm:1 the septum transversum (a mass of pluripotent mesoderm), pleuroperitoneal membranes, dorsal mesentery of the esophagus, and body wall musculature. Forming first in the cervical area, the septum transversum descends caudally by the eighth week of gestation, coordinated with sternal fusion and opposed by a rapid increase in

Congenital Diaphragmatic Hernias

The development of the diaphragmatic musculature creates potential gaps in predictable locations that are covered only by connective tissue and not infrequently allow for herniation of abdominal contents during fetal development, after birth, or in adulthood. Diagnoses that will be discussed are fetal diaphragmatic hernias, Bochdalek and Morgagni hernias, and diaphragmatic eventration. Presentation ranges from massive life-threatening hernias detected in utero to a small defect with herniation

Acquired Diaphragmatic Hernias

Herniation can also occur through developmentally normal diaphragm, without predisposing weakness, because of trauma or degeneration. Diaphragmatic hernias to be discussed in this category include hiatal hernia and traumatic diaphragmatic rupture.

Conclusions

Diaphragmatic hernias are frequently encountered in almost any radiologic practice. Differentiation of potentially life-threatening diagnoses from incidental and benign findings or other mimics is essential to effectively and efficiently triage patients, guide further workup, and assist the consulting surgeon in treatment planning.

References (32)

  • V. Schumpelick et al.

    Surgical embryology and anatomy of the diaphragm with surgical applications

    Surg Clin North Am

    (2000)
  • T. Tiryaki et al.

    Eventration of the diaphragm

    Asian J Surg

    (2006)
  • M.S. Shin et al.

    Bochdalek hernia of diaphragm in the adult: diagnosis by computed tomography

    Chest

    (1987)
  • H.-C. Yeh et al.

    Anatomic variations and abnormalities in the diaphragm seen with US

    Radiographics

    (1990)
  • C.I. Caskey et al.

    Aging of the diaphragm: a CT study

    Radiology

    (1989)
  • N.S. Adzick et al.

    Diaphragmatic hernia in the fetus: prenatal diagnosis and outcome in 94 cases

    J Pediatr Surg

    (1985)
  • D. Bohn

    Congenital diaphragmatic hernia

    Am J Respir Crit Care Med

    (2002)
  • L.F. Donnelly et al.

    Correlation between findings on chest radiography and survival in neonates with congenital diaphragmatic hernias

    AJR

    (1999)
  • M.L. Kulkarni et al.

    Eventration of the diaphragm and associations

    Indian J Pediatr

    (2007)
  • M.E. Mullins et al.

    Prevalence of incidental Bochdalek's hernia in a large adult population

    AJR

    (2001)
  • M.E. Gale

    Bochdalek hernia: prevalence and CT characteristics

    Radiology

    (1985)
  • M. Mei-Zahav et al.

    Bochdalek diaphragmatic hernia: not only a neonatal disease

    Arch Dis Child

    (2003)
  • T.J. Cole et al.

    Manifestations of gastrointestinal disease on chest radiographs

    Radiographics

    (1993)
  • J.D. Horton et al.

    Presentation and management of Morgagni hernias in adults: a review of 298 cases

    Surg Endosc

    (2007)
  • S.C. Gaerte et al.

    Fat-containing lesions of the chest

    Radiographics

    (2002)
  • G.M. Lee et al.

    CT imaging of abdominal hernias

    AJR

    (1993)
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