From the Guidelines
For a patient with increased work of breathing and a chest X-ray showing an elevated left diaphragm with distended bowel, you should first stabilize the patient with supplemental oxygen if needed, then obtain urgent surgical consultation as this presentation suggests possible diaphragmatic hernia or eventration. Order additional imaging such as a CT scan of the chest and abdomen with contrast to better visualize the anatomy and confirm the diagnosis, as recommended by the most recent study 1. While awaiting surgical evaluation, place the patient in an upright or semi-Fowler position to reduce pressure on the diaphragm, provide adequate pain control, and consider nasogastric tube placement to decompress the stomach if there is significant gastric distention. Monitor vital signs closely, including oxygen saturation, and be prepared for possible respiratory deterioration. This presentation is concerning because bowel herniation through the diaphragm can compromise lung function by occupying thoracic space and reducing lung capacity. The elevated diaphragm with bowel above it suggests either a congenital or acquired diaphragmatic defect, with the latter possibly resulting from trauma or increased intra-abdominal pressure. Prompt surgical intervention may be necessary to repair the defect and return the bowel to its normal anatomical position, as suggested by studies 1. Initial management should also include supportive treatment with intravenous crystalloids, anti-emetics, and bowel rest, as recommended by 1. It is essential to consider the possibility of bowel obstruction, as suggested by 1, and to evaluate the patient for signs of ischemia or perforation, which would require immediate surgical intervention. The use of CT imaging is crucial in diagnosing and managing diaphragmatic hernias, as it can help identify the location and size of the defect, as well as any complications such as ischemia or perforation 1. Overall, the management of a patient with an elevated left diaphragm and distended bowel requires a multidisciplinary approach, including surgical consultation, imaging studies, and supportive care, with the goal of improving morbidity, mortality, and quality of life outcomes.
From the Research
Patient Presentation
The patient presents with an elevated left diaphragm and distended bowel, as noted on a chest x-ray. This combination of findings suggests a potential issue with diaphragmatic function and abdominal pathology.
Potential Causes
- Diaphragmatic dysfunction, which can be caused by a variety of entities, including surgery, trauma, tumor, and infection 2
- Abdominal bloating and distension, which can be caused by food intolerances, previous infection, disordered visceral sensation, delayed intestinal transit, or abnormal viscero-somatic reflux 3
Diagnostic Approach
- Functional imaging with fluoroscopy, ultrasonography, or magnetic resonance imaging can be used to diagnose diaphragmatic dysfunction 2
- Evaluation of the abdomen in critically ill patients can be challenging, but imaging techniques such as computerized tomography, ultrasound, and magnetic resonance imaging can be useful 4, 5
- A thorough history and physical examination are essential in evaluating patients with acute abdominal pain 6
Treatment Options
- Treatment of diaphragmatic paralysis depends on the cause of the dysfunction and the severity of the symptoms, and may include plication and phrenic nerve stimulation 2
- Treatment of abdominal bloating and distension can be challenging, but may involve dietary changes, probiotics, antibiotics, prokinetic agents, antispasmodics, neuromodulators, and biofeedback 3