This document discusses the anatomy, physiology, imaging, and pathologies of the diaphragm. It describes the diaphragm's muscular origins and innervation. Normal chest x-rays show the diaphragm is 2-3 mm thick. Pathologies include diaphragmatic paralysis, ruptures from trauma, and hernias such as Bochdalek and Morgagni hernias. Tumors like leiomyosarcomas can also involve the diaphragm. Imaging plays a key role in evaluating diaphragmatic abnormalities.

1. IMAGING MODALITIES
OF DIAPHRAGM
DR. ARIF KHAN S

2. DIAPHRAGM (S)
• Diaphragm : Seperation
• Thoracic Diaphragm
• Pelvic Diaphragm
• Urogenital Diaphragm

3. THORACIC DIAPHRAGM (ANATOMY)
• Dome shaped
• Muscular fibres : orgin
Sternal – below XIPHOlD process ,
Costal - Inner surface of costal cartilages of
6th ribs ,
lumbar - Aponurotic arches of lumbar
vertebrae

4. • lumbocostal arches : 2 pairs
Medial lumbocostal arches : tendinous arch covering psoas major;
continuous medially with left crura ; attached to L2 vertebral body
and in the front of the transverse process of L1 and L2
Lateral lumbocostal arches : covers quadratus lumborum;
attached medially to the L1 transverse process and attached
laterally to the tip of the 12th rib
• Crurae : Right and Left ; Blends to the Anterior longitudinal
ligament of vertebrae
• CENTRAL TENDON: Strong aponeurosis. below pericardium

6. Aortic Hiatus (T12)
Oesophageal Hiatus (T10 )
Vena caval foramen (T8)
Lesser apertures
BLOOD SUPPLY
At
1.Costal margins – lower 5 intercostal A.
2. Abdominal surface – Rt & Lt Inf.Phrenic A.
3. Superior phrenic A. And Musculophrenic A
NERVE SUPPLY
Rt and Left phrenic N. & inter –costal N.

7. NORMAL CHEST X-RAY

9. • Normal Diaphragm is 2-3 mm thick
• Which is normally not measurable In right side unless
there is free peritoneal gas or bowel loop separating
the liver from diaphragm.
• In the left side the combined stomach wall and
diaphragm form linear density of 5-8 mm thick.
• Thickening in most cases are normal.
• Pathological thickening is seen in
1. Tumors of diaphragm; stomach & pleura
2. Subpulmonary fluid
3. Diaphragmatic humps
4. Abdominal lesions : splenomegaly, Hepatomegaly
Sub-phrenic abscess

10. NORMAL VARIATIONS
• Scalloping: Rt side common;
• Muscle slips
• Dipahragmatic humps and
Dromedary hump
• Eventration
• Accessory Diaphragm

11. DIAPHRAGM (PHYSIOLOGY)
• Function : Seperation between Thoracic and Abdominal cavities.
Aid in Respiration as Chief Inspiratory muscle
• Two components : non contractile central tendon ;contracting muscle fibres
• Contraction of muscles induce intra-pleural pressure  cause air to be sucked in the
lungs
• Contributes 3/4th of inspiratory volumes at the vital capacity.
• Normal movement is 3-5 cm
• Abnormal movement or reduced movement is seen in paralysis of diaphragm
• Movement of diaphragm can be assessed using USG or Flouroscopy

12. PATHOLOGIES OF DIAPHRAGM

13. DIAPHRAGMATIC PARALYSIS
• Due to injury to Phrenic nerve.
• Unilateral or Bilateral
• Increase load can cause respiratory failure
• Assosciated with conditions like : Spinal cord transection, Multiple sclerosis, Amyotrophic lateral
Sclerosis, Cervical spondylosis GBS,
• Isolated Phrenic Nerve dysfunction: Compression by tumor, Cardiac surgery cold injury, blunt trauma,
etc.

14. • Chest radiograph show elevated hemidiaphragm
and Atelectasis of lung
• Flouroscopy aid s in clear visualization of the
movement of the diaphragm
• Sniff Test: Parodoxical Elevation of diaphragm in
inspiration
• Other tests : PFT, EMG and phrenic nerve
stimulation
• USG

15. DIAPHRAGMATIC MOVEMENT
ASSESSEMENT THORACIC ULTRASOUND:
• Principles:
• Changes in diaphragm thickness during
contraction.
(chronically paralyzed diaphragm is atrophic and
does not thicken during inspiration )
• Should be assessed in two areas Liver at the
Right and Spleen window on the left
• Low frequency probes are used.

16. POST PROCEDURE INDUCED
DIAPHRAGMATIC PARALYSIS (TRANSIENT
TYPE)

17. FIG 1 FIG 2

18. RUPTURE OF DIAPHRAGM
• Traumatic diaphragmatic injuries occur in 0.8%–8% of patients who sustain blunt trauma. Up to 90% of
diaphragmatic ruptures from blunt trauma occur in young men after motor vehicle accidents
• Both bilateral tears and extension of tears into the central tendon are uncommon. They are reported in
2%–6% of patients with diaphragmatic injury.
• Mechanisms of injuries include a lateral impact, and shears the diaphragm, and a direct frontal impact

19. • Most ruptures are longer than 10 cm and occur at the
posterolateral aspect of the hemidiaphragm between
the lumbar and intercostal attachments and spread in
a radial direction
• Penetrating injuries such as gunshot wounds or stab
injuries are more random
Sites of injuries. Drawing shows radial (A), transverse
(B), and central (C) ruptures and a peripheral
detachment (D). Radial tears appear to be the most
frequently found injury at surgery, whereas
peripheral detachments are the least frequent.

20. ASSOSCIATED INJURIES
• Common : pelvic fractures (40%–55%), splenic
injuries (60%), and renal injuries
• High frequency of liver injuries, which are more
frequently associated with right than with left
diaphragmatic tears
• Thoracic injuries : pneumohemothoraces and rib
fractures are seen in 90% of patients. Aortic thoracic
injuries are reported in 5% of patients

21. DIAPHRAGM INJURY (IMAGING)
Chest X-ray :
(a) intrathoracic herniation of a hollow viscus (stomach, colon,
small bowel) with or without focal constriction of the viscus
at the site of the tear (collar sign)
(b) visualization of a nasogastric tube above the
hemidiaphragm on the left side
• Findings suggestive of hemidiaphragmatic rupture include
elevation of the hemidiaphragm, distortion or obliteration of
the outline of the hemidiaphragm, and contralateral shift of
the mediastinum

22. • CT CHEST:
• Helical CT has proved to be more valuable in the detection of
diaphragmatic injuries with a sensitivity of 71%
• Findings :
• 1. Direct discontinuity of the hemidiaphragm;
sensitivity 73%, specificity 90%.
• 2. Intrathoracic herniation of abdominal contents;
sensitivity 55%, specificity 100%.
• 3. The collar sign: sensitivity 36% with conventional CT
63% with helical CT. On the right side, the collar sign can
appear as a focal indentation of the liver, a subtle sign easily
overlooked
• 4. The dependent viscera sign: sensitivity: 100%: left-
sided 83%: right-sided
when a patient with a ruptured diaphragm lies supine at CT
examination, the herniated viscera (bowel or solid organs)
are no longer supported posteriorly by the injured
diaphragm and fall to a dependent position against the
posterior ribs

23. CONGENITAL DIAPHRAGMATIC HERNIA
• Diaphragmatic hernias include Bochdalek
(posterolateral), Morgagni (retrosternal),
and hiatal hernias
• Antenatal USG scan can diagnose all
types earlier
• USG can in aid in determining the
survivability of the foetus.
• Congenital diaphragmatic hernia (CDH) is
a major surgical emergency in newborns.
The key to survival lies in prompt
diagnosis and treatment
• Pulmonary hypertension and Pulmonary
hypoplasia are complications

24. MORGAGNI’S HERNIA
• Anterior defect of the diaphragm
• Retrosternal, or parasternal hernia
• herniation through the foramina of Morgagni
• Associated pericardial defect , pleural and or pericardial effusion may b seen
• Contents : the liver, spleen, and omentum
• D/d s
Thymoma, Rt middle lobe collapse, hydatid cyst, fibrous tumor of the pleura
Cardiophrenic angle lesions:
lymphadenopathy : metastasis, lymphoma, reactional
Pericardial Cyst ; pericardial lipomatosis

25. MORGAGNI HERNIA
• Morgagni hernia in a 2-year-old child.
Lateral chest radiograph shows
herniation of a bowel loop (arrows) in a
classic location through an
anteromedial defect.
• Anterior herniation of bowel loops on a
lateral chest radiograph is the typical
finding. Other herniated viscera include
the liver, spleen, and omentum.

26. FIG 1 FIG 2

27. FIG 1 ` FIG 2

28. FIG 1 FIG 2

29. BOCHDALEK HERNIA
• Posterior aspect
• defect in the posterior attachment of
the diaphragm when there is a failure
of pleuroperitoneal membrane closure
in utero
• most frequently left sided.

30. BOCHDALEK HERNIA
• Frontal radiograph of the chest in a
newborn shows herniation of bowel
loops into the left hemithorax with
displacement of the heart to the right,
findings consistent with left Bochdalek
hernia.
• The nasogastric tube (arrows) in the
left hemithorax indicates the
intrathoracic stomach.

31. HIATUS HERNIA
• A .K.a. oesophageal hiatal hernia
• herniation of stomach through the oesophageal hiatus of the diaphragm
• Types
1. Sliding 2. roling (para-oesophageal)
Content : always Stomach ; rarely with bowel loops (if the defect is large enough)
D/ds
Lung abscess (Retro- cardiac)
Empyema , epiphrenic oesophageal diverticulum

32. FIG 1 FIG 2

33. FIG 1 FIG 2

34. FIG 1 FIG 2

35. CONGENITAL DIAPHRAGMATIC
EVENTRATION
• Abnormal elevation of part or all of an otherwise intact hemidiaphragm into the chest
cavity is termed eventration.
• CAUSES
congenital absence of muscle fibers
focal dyskinesia and weakness from ischemia, infarct,
neuromuscular dysfunction.
• The anteromedial aspect of the right side
• D/Ds
Morgagni hernia, pericardial cyst, paraesophageal hernia, bronchogenic cyst, and tumor.

36. • Focal eventration (arrow) at the anteromedial aspect of the right hemidiaphragm.
• The eventration contains part of the liver.

37. • Eventration (arrow) at the left
hemidiaphragm at seen at birth.
• Complete eventration of a
hemidiaphragm is more common in
males and typically occurs on the left
side.

38. TUMORS
• Diaphragmatic tumors may be divided
• : (i) primary benign neoplasms;
• (2) primary malignant neoplasms;
• (3) secondary malignant neoplasms;
• (4) cysts;
• (5) inflammatory lesions
• (6) endometriosis.

39. PRIMARY BENIGN NEOPLASMS;
• Can arise from any of the normal tissue
components .
Eg: Lipomas, fibromas, angiofi bromas,
neurofibromas and neurilemmomas are
common;
Adrenal cortical adenoma, liver cell adenoma,
chondroma, hamartorna and mesothelioma
are rarer
• Diagnosed mostly post mortem biopsy,
• X-ray appearance as irregularity in
diaphragm

40. PRIMARY MALIGNANT NEOPLASMS
Majority are fibrous tissue origin.
Eg; (fibrosarcoma, fibro-myo-sarcoma, fibro-
angio-endothelioma) or undifferentiated
sarcomas.
• mixed cell sarcoma, myosarcoma,
rhabdomyosarcoma,
• Of the reported primary tumors of the
diaphragm, malignant neoplasms
predominate in a ratio of about 60 :40.

41. LEIOMYOSARCOMA

42. • SECONADARY MALIGNANT NEOPLASMS
• Secondary malignant neoplasms of the diaphragm
may he due to direct invasion
• from adjacent lesions or metastatic spread OR
through vascular channels.
• Resembles benign tumours radiogrpahically.
• Blood born mets are rare
• Direct spread from lver ,lungs (incl pleura), stomach,
kidneys adrenaals are seen ;
• Others include chondro sarcoma , Hodgkin’s disease

43. SECONDARY DUE TO PRIMARY OVARIAN
CARCINOMA

44. SPLENIC FLEXURE COLON CARCINOMA
INVADING THRU DIAPHRAGM

45. FIG 1 FIG 2

46. SPOTTERS

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