Elevated hemidiaphragm

Case contribution: Dr Radhiana Hassan


  • A 44 years old with epigastric pain
  • CXR requested to rule out perforated peptic ulcer disease

Radiographic findings:

  • Right hemidiaphragm is significantly higher than the left side
  • The difference between dome height is more than 3 cm
  • Blunting of right costophrenic angle with meniscus sign
  • No free air under the diaphragm
  • Lungs are clear

Impression: Elevated right hemidiaphragm




Normal radiographic anatomy of diaphragm:

  • Both diagram contours should be visible medially to the spine
  • Both diaphragm should form a sharp margin with lateral chest wall
  • During inspiration, the top of right diaphragmatic dome coincides with the end of anterior 5th or 6th rib
  • It can be slightly higher in obese, the elderly and young infants
  • In over 90% of normal people the right hemidiaphragm is higher than the left
  • The left hemidiaphragm is usually 1.5 -3.0 cm lower than the right due to heart’s weight
  • In about 10% of population the left hemidiaphragm is at the same level or higher than the right.

Causes of elevated hemidiaphragm

  • Above the diaphragm
    • Decreased lung volume: atelectasis, collapsed, prior lobectomy or pneumonectomy, pulmonary hypoplasia
    • Pneumonia or pleuritic pain
  • Diaphragm
    • Phrenic nerve palsy, diaphragmatic eventration, contralateral stroke
  • Below the diaphragm
    • Abdominal tumour such as liver metastasis or primary liver disease
    • Subphrenic abscess
    • Distended stomach or colon including Chilaiditi syndrome
  • Others
    • Dorsal scoliosis
    • Ribs fracture

Progress of patient:

  • Ultrasound showed enlarged liver with multiple lesions within the liver parenchyma
  • Subsequent investigations revealed metastatic liver disease secondary from GI malignancy



Author: radhianahassan