An obscured hemidiaphragm may be due to adjacent lung disease
An abnormal diaphragm position may indicate a serious pathology
Pneumoperitoneum
Every time you check a chest X-ray you should make sure there is no free intra-abdominal air under the diaphragm (pneumoperitoneum). This is a sign of bowel perforation.
The diaphragm is crisply defined on both sides (arrowheads)
Air under the diaphragm (asterisks) is seen as crescents of relatively low density (black)
Black air can be seen on both sides of the bowel wall (blue line) – this is known as the double-wall sign or Rigler's sign (usually only seen on abdominal X-rays)
Clinical information
Acute, severe abdominal pain
Abdominal guarding on examination
Risk factors for peptic ulceration included smoking, high alcohol intake, and long term use of non-steroidal anti-inflammatory drugs
Diagnosis
Pneumoperitoneum – at laparotomy a perforated duodenal ulcer was found
Diaphragm contour abnormalities
The normal hemi-diaphragms form distinct dome-shaped contours against the adjacent lungs. If these contours are obscured it is often possible to determine the location of lung disease. For example, the lower lobes of both lungs lie directly in contact with each hemi-diaphragm. Consolidation of the lower lobes, therefore, obscures the crisp contour of the adjacent hemi-diaphragm.
The left hemidiaphragm is obscured (red line = normal position)
Consolidation of the left lung base (highlighted area) extends behind the heart
Clinical information
Cough, high temperature and raised white cell count
Diagnosis
Left lower lobe pneumonia
Raised hemidiaphragm
The right hemi-diaphragm usually lies at a level slightly above the left. There are many possible causes of a raised hemidiaphragm such as damage to the phrenic nerve, lung disease causing volume loss, congenital causes such as a diaphragmatic hernia, or trauma to the diaphragm.