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Communications to the Editor |

Catamenial Pneumothorax: An Example of Porous Diaphragm Syndromes? FREE TO VIEW

Kazuhiro Funatsu, MD
Author and Funding Information

Affiliations: Funatsu Clinic, Fukuoka, Japan,  Mt. Sinai School of Medicine, New York, NY

Correspondence to: Kazuhiro Funatsu, MD, Funatsu Clinic, Akama 963, Munakata, Fukuoka 811-4146, Japan; e-mail: munakazu@fine.ocn.ne.jp



Chest. 2002;122(5):1865. doi:10.1378/chest.122.5.1865
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To the Editor:

I recently read the letter of Dr. Kirschner (November 2000),1who commented on my letter (December 1999).2 I would like to address some remarks and questions raised by Dr. Kirschner.

First, is the pathogenesis of catamenial pneumothorax recognized as the transdiaphragmatic passage of gas? If this is the cause, then why does this disease occur in connection with menses?

Second, if the pore hypothesis is correct, then catamenial pneumothoraces seem to occur bilaterally due to the negative intrathoracic pressure.

Third, the subdiaphragmatic lymphatics communicate with the diaphragmatic pleura but not with the intrathoracic space.3As a result, hydro- or pneumoperitoneum does not seem to develop hydro- or pneumothorax in a normal lymphatic state, even if fluid or gas are absorbed from the stomata. Furthermore, based on the fact that the absorption of intraperitoneal fluid is more extensive in the right hemidiaphragm,4 I think that the distribution of the peritoneal stomata may have a right-side predominancy, and that diseases caused by such a physiologic function appear to have the same tendency.

Fourth, the article by Allen3 appears to have solved the controversy regarding whether peritoneal stomata represent normal openings or not. I quoted his article in my previous letter.2

Further studies are called for to clarify this disease, an example of the pore hypothesis, the peritoneal stoma hypothesis, or others.

References

Kirschner, PA (2000) Catamenial pneumothorax: an example of porous diaphragm syndromes [letter].Chest118,1519-1520. [CrossRef]
 
Funatsu, K, Tsuru, M, Hayabuchi, N Catamenial pneumothorax and its relation to the peritoneal stomata of the diaphragm [letter]. Chest. 1999;;116 ,.:1843
 
Allen, L The peritoneal stomata.Anat Rec1936;67,89-103
 
Yoffey, JM, Courtice, FC Lymph flow from regional lymphatics. Yoffey, JM Courtice, FC eds.Lymphatics, lymph, and the lymphomyeloid complex. 1st ed.1970,295-309 Academic Press. New York, NY:
 

To the Editor:

My comments to all of the remarks posed by Dr. Funatsu can be found in my paper entitled “Porous Diaphragm Syndromes.”1 In that article, I collected and documented the many disparate clinical syndromes, united by a common denominator, namely, gross diaphragmatic defects. This is the “gestalt” of this article.

These defects facilitate the phenomenon of peritoneopleural transphrenic passage of air (catamenial pneumothorax), other gases (CO2) in artificial pneumoperitoneum, and laparoscopy fluids (ascites from liver cirrhosis, and peritoneal dialysis fluid in treatment of renal failure), and possibly Meigs syndrome and tissue (endometriosis), as well as blood, exudate, chyle, bile, and urine.

The right-sided predominance of the thoracic manifestations of this phenomenon is, I believe, the result of the anatomic difference between the two upper quadrants of the abdomen. In the right upper quadrant, the solid, more-or-less-fixed liver acts as a piston when the right hemidiaphragm contracts, raising the intraperitoneal pressure locally, trapping the offending substance (ie, air, fluid etc.), and forcing substances through preexisting or acquired holes in the diaphragm. In the left upper quadrant, the relatively loose stomach, colon, and spleen are not mechanically likely to produce the same pressure changes as on the right side.

I cannot accept a lymphatic mechanism to explain these phenomena, nor can I consider the microscopic stomata to play any role in these porous diaphragm syndromes, as they are too small to permit such massive rapid fluid and/or gaseous shifts into the chest.

References
Kirschner, PA Porous diaphragm syndromes.Chest Surg Clin N Am1998;8,449-472. [PubMed]
 

Figures

Tables

References

Kirschner, PA (2000) Catamenial pneumothorax: an example of porous diaphragm syndromes [letter].Chest118,1519-1520. [CrossRef]
 
Funatsu, K, Tsuru, M, Hayabuchi, N Catamenial pneumothorax and its relation to the peritoneal stomata of the diaphragm [letter]. Chest. 1999;;116 ,.:1843
 
Allen, L The peritoneal stomata.Anat Rec1936;67,89-103
 
Yoffey, JM, Courtice, FC Lymph flow from regional lymphatics. Yoffey, JM Courtice, FC eds.Lymphatics, lymph, and the lymphomyeloid complex. 1st ed.1970,295-309 Academic Press. New York, NY:
 
Kirschner, PA Porous diaphragm syndromes.Chest Surg Clin N Am1998;8,449-472. [PubMed]
 
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