Diaphragmatic Eventration Diagnosis and Management

Differential Diagnosis

Diaphragmatic paralysis shows paradoxical motion during respiration on fluoroscopic examination, moving cephalad during inspiration instead of caudally, according to the American College of Radiology 1
Diaphragmatic hernia can be diagnosed using CT scan, which is the gold standard, showing discontinuity of the diaphragm, herniation of abdominal contents into thorax, "collar sign", or "dependent viscera sign", as recommended by the World Journal of Emergency Surgery 2
Right-sided hernias are less common than left-sided, occurring in 12-40% of cases, due to the protective effect of the liver, as reported by the World Journal of Emergency Surgery 3

Chest X-ray is the first-line study for initial evaluation, showing hemidiaphragm elevation >2.5 cm, according to the World Journal of Emergency Surgery 2
Fluoroscopy is used to assess for paradoxical motion, which is present in paralysis and absent in eventration, as recommended by the American College of Radiology 1
CT scan with contrast is used to evaluate for visceral herniation, diaphragmatic discontinuity, and complications like bowel ischemia, as recommended by the World Journal of Emergency Surgery 2

Symptomatic patients presenting with dyspnea, orthopnea, recurrent pneumonia, tachypnea, failure to thrive, or non-specific gastrointestinal symptoms require surgical intervention, according to the American College of Surgeons 4
Diaphragmatic plication is the established treatment, with minimally invasive thoracoscopic plication being the preferred approach for stable patients, using 3-port video-assisted thoracoscopic surgery (VATS), as recommended by the Society of Thoracic Surgeons 1
Primary repair using non-absorbable sutures is recommended when possible, and mesh reinforcement is recommended for defects >3 cm to prevent recurrence, as recommended by the Society of Thoracic Surgeons 1

Unrecognized eventration can lead to unnecessary workups for other pathologies, and initial chest X-ray findings can be misinterpreted in 25% of diaphragmatic pathology cases, as reported by the World Journal of Emergency Surgery 2
Right-sided diaphragmatic injuries have a 50% delayed diagnosis rate, often presenting with complications, as reported by the World Journal of Emergency Surgery 3
If CT shows visceral herniation with signs of bowel ischemia, this represents a surgical emergency requiring immediate intervention for potential strangulation, as recommended by the World Journal of Emergency Surgery 2, 3