A 51 yo female presents to the ED with severe abdominal pain that started as a dull ache several weeks ago, but acutely worsened about one hour prior to arrival. She is in distress, abdomen is soft and she has epigastric tenderness. Her presentation is concerning enough for the team to order a STAT upright CXR. What's the diagnosis? Scroll down for answer.

Answer: Diaphragmatic Rupture due to undiagnosed Congenital Hernia

• Presentation of non-traumatic diaphragmatic injuries is often insidious.
• Though often found on imaging, sometimes can auscultate bowel sounds in the thorax. 
• Though this case was non-traumatic (due to a congenital hernia), don’t forget → all penetrating injuries from the nipple to the umbilicus have the potential to injure the diaphragm!
• Even a small laceration may be initially asymptomatic, but can enlarge over time, causing rupture of abdominal contents into the chest months later
• Management? Immediate surgical consult. All diaphragmatic injuries require operative intervention. 

References:

Tintinalli, JE. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education LLC, 2016.