An 82-year-old female patient with a history of chest pain, right side, and dyspnea for three months.
Clinical history: An 82-year-old female patient with a history of chest pain, right side, and dyspnea for three months.
CT scanogram: radio-opacity displaced right lung fields with radiolucencies within. Opacity seen until level of aortic arch. Heart is slightly displaced to the left.
CT chest lung window (images 2-11): Omental fat and bowel loops herniating into right chest. Liver is in normal position.
Mesentric vessels seen to converge at opening on right side in anterior mediastinum behind sternum from foramen or morgagni.
Images 12 - 14: Mesentric vessels seen to converge at opening on right side in anterior mediastinum behind sternum from foramen or morgagni.
Diagnosis: Morgagni hernia right side
Discussion: Foramen of Morgagni hernias are rare diaphragmatic hernias, usually occurring on the right and located in the anterior mediastinum because of the retrosternal location of the foramen of Morgagni, described as the anterior diaphragmatic defect.
Adult patients diagnosed with a foramen of Morgagni hernia are usually asymptomatic. Although most remain asymptomatic, some patients develop symptoms of dyspnea, cough, or sternal pain, depending on the extent of the hernia. The hernia usually contains omental fat, and bowel and liver are found less commonly in the hernia contents. In adults, foramen of Morgagni hernias are also usually associated with obesity, trauma, weight lifting or other causes of increased intra-abdominal pressure.
Congenital diaphragmatic hernias are a rare form of diaphragmatic hernias during adult life. They are characterized by their location. Bochdalek’s hernias are located posterolaterally and Morgagni hernias are located anteriorly. They may be mono- or bilateral. The incidence is 1/5,000 in every live birth. Ninety-eight percent of congenital diaphragmatic hernias are Bochdalek (posterolateral), and 2 percent are Morgagni (retrosternal or parasternal) hernias. Though Morgagni hernia is a congenital hernia, it is rarely diagnosed during the early years of life. It is generally asymptomatic in adults and detected incidentally on the chest X-ray.
Here, in view of the rareness of its appearance, we report a 82 -year-old female case with a Morgagni hernia diagnosed incidentally on the CT chest.
Morgagni hernia occurs as a herniation of intra-abdominal organs into the thorax through a parasternal or retrosternal defect of the diaphragm. Herniation most frequently includes omentum and colon segments; however, stomach, liver and intestines might also be herniated. The herniated structure in the case presented here was also omental fat tissue. The symptomatology of Morgagni hernia is quite variable; the cases can be asymptomatic or
may present with a clinical picture of acute respiratory distress. Asymptomatic cases or cases with a course of only slight chest or abdominal pain till advanced age have been reported in the literature.
However, constipation, diarrhea, development retardation, vomiting, post-prandial distension, other gastrointestinal symptoms resembling gallbladder disorders or peptic ulcer, as well as repetitious pulmonary infections and acute respiratory distress related to the respiratory system can be observed in Morgagni hernia cases, who are more symptomatic during childhood than the adults.
In diaphragmatic hernia cases, a decrease in the respiratory sounds or presence of colonic sounds on chest examination is a significant finding in diagnosis. Risk of complications is quite high, with the main complications being gastric volvulus and colonic obstruction.
Plain pulmonary roentgenogram, radiological studies of the gastrointestinal system with contrast material, computerized tomography and magnetic resonance imaging studies are helpful in diagnosis. On the pulmonary roentgenogram, a space-occupying lesion is detected at the anterior mediastinum and intestinal loops might sometimes be seen at pulmonary areas. In cases with no emergency, contrasted passage radiological studies of the stomachduodenum and/or colon might be performed. The nature of the mass detected in anterior mediastinum might be evaluated through CT scanning. Space occupying lesions of the anterior mediastinum such as pleuro-pericardial cysts, pleural mesothelioma, pericardial fat cushion, mediastinal lipoma, diaphragmatic tumors or cysts, thymoma and front thoracal wall tumors should be considered in differential diagnosis.
Harpreet Singh, MD, JP Scan private diagnostic center, Khanna, Punjab, India