6 ELEVATED DIAPHRAGM

Fig. 6.1 

QUESTIONS
1. Which one the following diagnoses is most likely in the case illustrated in Fig. 6.1?
a. Hepatomegaly.
b. Interposition of the colon.
c. Right upper lobe atelectasis.
d. Phrenic nerve paralysis.
e. Right upper lobe pneumonia.

2. Which of the following is least likely to be associated with pleural effusion?

a. Primary lung tumor.
b. Interposition of colon.
c. Subphrenic abscess.
d. Echinococcal cyst.
e. Metastasis.

3. Which of the following is not true of phrenic nerve paralysis?

a. Results in complete loss of motion of the diaphragm at fluoroscopy.
b. May be secondary to primary lung tumor in the apex.
c. May be secondary to mediastinal malignant tumor.
d. Occasionally is idiopathic.
e. Results in paradoxic motion of the diaphragm.
   

63
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64  PART 1  Chest Wall, Pleura, and Mediastinum

Chart 6.1    ELEVATED DIAPHRAGM

I. Subpulmonic pleural effusion32,53

II. Abdominal disease
A. Subphrenic abscess
B. Distended stomach
C. Interposition of the colon
D. Liver mass (e.g., tumor, abscess, echinococcal cyst)
III. Decreased lung volume
A. Atelectasis
B. Postoperative lobectomy and pneumonectomy
C. Hypoplastic lung
IV. Phrenic nerve paralysis
A. Primary lung cancer
B. Malignant mediastinal tumor
C. Iatrogenic
D. Idiopathic
V. Diaphragmatic hernia336 (e.g., foramina of Morgagni and Bochdalek)
VI. Eventration of the diaphragm
VII. Traumatic rupture of the diaphragm
VIII. Diaphragmatic tumor (e.g., lipoma,153 fibroma, mesothelioma, metastasis,
lymphoma)

Discussion
Elevation of the diaphragm offers a variety of radiologic challenges (Chart 6.1).
When both sides of the diaphragm are symmetrically elevated, the differential
is significantly different from that with unilateral elevation. The most common
cause of elevation of both sides of the diaphragm is failure of the patient to inspire
deeply. This is frequently voluntary, but may be an indicator of a significant patho-
logic process. Obesity is probably the most common abnormality resulting in low
lung volume. A similar appearance may be produced by a variety of abdominal
conditions, including ascites and large abdominal masses. Bilateral atelectasis may
also result in the elevation of both sides of the diaphragm, but is usually identifiable
by increased opacity in the lung bases. Restrictive pulmonary diseases may likewise
result in elevation of both sides of the diaphragm (see Cicatrizing Atelectasis in
Chapter 13).

SUBPULMONIC PLEURAL EFFUSION

Subpulmonic pleural effusion is an important cause of apparent elevation of the
diaphragm.32,53 This is usually unilateral, but on occasion may be bilateral. The
posteroanterior view may suggest this diagnosis when the diaphragm appears flat,
with a lateral meniscus in the costophrenic angle (Fig. 6.2, A), or when the dome
of the diaphragm is more lateral than normal, with an abrupt drop-off (Fig. 6.3, A).
The lateral view may help confirm this impression by demonstrating a posterior
meniscus (see Fig. 6.3, B). The diagnosis is often confirmed with a lateral decubi-
tus view (see Fig. 6.2, B). Caution must be exercised in evaluating a subpulmonic
pleural effusion because pleural effusions may be associated with other significant
abnormalities, such as a subphrenic abscess, primary lung tumor, and liver masses
(including abscesses and echinococcal cysts) that result in true elevation of the
diaphragm. 

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 CHAPTER 6  Elevated Diaphragm  65

B
Fig. 6.2  A, The opacification of the left lower thorax is flat rather than domed, with a lateral menis-
cus. This is the result of a large fluid collection between the base of the lung and the diaphragm. B, Left
lateral decubitus view confirms the presence of a large, free-flowing pleural effusion.

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66  PART 1  Chest Wall, Pleura, and Mediastinum

B
Fig. 6.3  A, Note that the left hemidiaphragm is not only elevated but the dome is more lateral
than the normal right side due to a subpulmonic pleural effusion. B, Lateral view reveals a sharp right
costophrenic angle but blunting of the left costophrenic angle. Only the posterior portion of the left
hemidiaphragm appears elevated, and it appears to end at the major fissure. This unusual appearance
is another clue to a subpulmonic pleural effusion, mimicking elevation of the left hemidiaphragm.

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 CHAPTER 6  Elevated Diaphragm  67

ALTERED PULMONARY VOLUME

Atelectasis is a common cause of diaphragmatic elevation and is recognizable by the
associated pulmonary opacity. Elevation of the diaphragm is an expected complica-
tion of lower-lobe, lingula, or middle-lobe atelectasis, but is also seen in upper-lobe
atelectasis (see Fig. 6.1). (Answer to question 1 is c.) Postoperative volume loss should
be recognized easily in cases with rib defects, metallic sutures, and shift of the heart or
mediastinum. 

ABDOMINAL DISEASES
A subphrenic abscess is not a rare cause of unilateral elevation of the diaphragm
following abdominal surgery. It is usually accompanied by pleural effusion. Chest
radiographs alone may confirm the diagnosis when localized collections of air are dem-
onstrated below the diaphragm (see Fig. 4.2, A and B). Ultrasound is the least invasive
method for confirming the diagnosis, and it is virtually diagnostic when localized fluid
collections are demonstrated below the diaphragm.
Distended abdominal viscera, such as the colon and stomach, may occasionally
elevate one side of the diaphragm. Interposition of the colon is a completely benign
condition in which the colon is interposed between the liver and right side of the
diaphragm. It may result in elevation of the right side of the diaphragm, but is not an
adequate explanation for pleural effusion. (Answer to question 2 is b.) Occasionally,
large liver masses elevate the right diaphragm, and computed tomography (CT) with
biopsy may be required to confirm the diagnosis. 

PHRENIC NERVE PARALYSIS

Phrenic nerve paralysis is a common cause of elevation of one side of the diaphragm. It
may be due to a variety of problems, including primary lung cancer, malignant medi-
astinal tumors, and surgery of the mediastinum. It may even be idiopathic. The combi-
nation of a lung or mediastinal mass and elevation of the diaphragm strongly suggests
phrenic nerve paralysis. The condition can be confirmed by fluoroscopy, which will
reveal paradoxic motion of the diaphragm—that is, as the patient inspires, the para-
lyzed side of the diaphragm appears to rise. This may be associated with slight flutter
and is best demonstrated with the patient in the lateral position. (Answer to question
3 is a.) A sniff accentuates diaphragmatic motion and is therefore useful in eliciting
paradoxic motion. 

EVENTRATION OF THE DIAPHRAGM

Eventration of the diaphragm is similar to paralysis but represents an area of weak-
ness and thinning of the diaphragm. With eventration, there may be motion of the
diaphragm but a smaller excursion between inspiration and expiration. It should not
entail a paradoxic movement of the diaphragm. In infancy, eventration may result
in elevation of a large portion of the diaphragm. In these cases, the entire leaf of the
diaphragm may consist of thin fibrous tissue. Older patients frequently have localized
irregularities of the diaphragm that lead to a lobulated appearance but are of little
pathologic significance. 

TRAUMATIC RUPTURE OF THE DIAPHRAGM

Traumatic rupture of the diaphragm may result in apparent elevation of the diaphragm
with intrathoracic herniation of an intraabdominal viscus. Left rupture with hernia-
tion of the stomach, small bowel, or colon often results in a lucent structure adjacent
to the heart (Fig. 6.4). These structures are likely to contain air, fluid, or air-fluid levels
in the left side of the chest rather than an elevation of the left hemidiaphragm. When
there is a large amount of fluid in these structures, the radiologic appearance may be

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68  PART 1  Chest Wall, Pleura, and Mediastinum

Fig. 6.4  This is a common appearance for traumatic rupture of the left hemidiaphragm. The elevated
air-filled stomach following thoracoabdominal trauma should strongly suggest this diagnosis. Also,
note the shift of the mediastinum to the right, indicating a space-occupying abnormality in the lower
left thorax.

that of near-opacification of the left hemithorax. Right-sided injuries with hernia-

tion of the liver are often more difficult to recognize.263 In this situation, the liver
herniates into the right hemithorax and simulates elevation of the diaphragm (Fig.
6.5, A and B), which might be mistakenly attributed to paralysis, subphrenic pleural
effusion, or atelectasis with elevation of the diaphragm. Diaphragmatic rupture is fre-
quently associated with other signs of chest or abdominal trauma, including multiple
fractures. Because of the severity of the injury, it may also be associated with pulmo-
nary contusion and chest wall vascular injury, leading to pleural effusion. Although
these signs of significant thoracic trauma should indicate the possibility of diaphrag-
matic injury, they may also obscure the direct signs that permit a confident diagnosis.
Chest radiographs may provide the first clues to suspect the diagnosis, but CT with
multiplanar imaging is more sensitive and specific for confirming the diagnosis (see
Fig. 6.5, C and D). 

DIAPHRAGMATIC TUMOR
Mesothelioma, fibroma, and lipoma may produce an apparent elevation of the dia-
phragm when the tumor assumes a massive size, but this is an infrequent occur-
rence. Serial radiographs may confirm growth of the mass, and CT should confirm the
diagnosis. 

Top 5 Diagnoses: Elevated Diaphragm

1. Eventration
2. Subpulmonic pleural effusion (apparent elevation of the diaphragm)
3. Atelectasis
4. Phrenic nerve paralysis
5. Diaphragmatic hernias (including traumatic hernias) 

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 CHAPTER 6  Elevated Diaphragm  69

Left

B D
Fig. 6.5  A, The opacification of the right hemithorax could be the result of atelectasis of the right
middle and lower lobes, a subpulmonic pleural effusion, or elevation of the diaphragm. B, Lateral chest
radiograph shows a large opacity in the right lower thorax, which changes contour near the region of
the oblique fissure and is suggestive of middle- and lower-lobe atelectasis. However, with the history of
major abdominal trauma, a diaphragmatic injury should be considered. C, Coronal CT image through
the anterior chest and abdomen reveals herniation of liver and bowel into the chest. D, Coronal CT
scan through the posterior chest and abdomen confirms herniation of the liver, with the additional
finding of inversion of the liver. Note the position of the gallbladder. This is a diaphragmatic rupture,
with herniation and volvulus of the liver.

Summary
Subpulmonic pleural effusion is the problem that usually mimics diaphragmatic eleva-
tion. It should be distinguished from true diaphragmatic elevation with lateral decubitus
views.

The most common causes of diaphragmatic elevation are atelectasis, abdominal mass-
es, eventration of the diaphragm, and phrenic nerve paralysis.

Abdominal masses, such as subphrenic abscess and liver masses (including tumors, ab-
scesses, and even echinococcal cysts), must be considered in the differential diagnosis
of an elevated right hemidiaphragm.

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70  PART 1  Chest Wall, Pleura, and Mediastinum

Traumatic rupture of the diaphragm may mimic elevation of the diaphragm by per-
mitting herniation of the liver into the right hemithorax or stomach, spleen, and
bowel into the left hemithorax. This diagnosis should be considered when there
is a history of significant abdominal or chest trauma and the appearance of a high
hemidiaphragm.

ANSWER GUIDE
Legend for introductory figure

Fig. 6.1 Elevated right hemidiaphragm in this patient with lung cancer could have re-
sulted from phrenic nerve paralysis, but the chest radiograph reveals additional findings of
right upper lobe atelectasis. Note increased opacity and elevation of the horizontal fissure.

ANSWERS
1. c  2. b  3. a

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