Peer Reviewed

Photoclinic

Morgagni Hernia

Volume 58 - Issue 7 - July 2018

Authors:
Yih Ying (Eva) Yuan, MD, and Mohamed Badawy, MD
UT Southwestern Medical Center/Children’s Medical Center Dallas, Texas

Citation:
Yuan YYE, Badawy M. Morgagni hernia. Consultant. 2018;58(7):e196.

 

A 9-month-old girl presented to the emergency department (ED) during the winter with a 4-day history of rhinorrhea, a 2-day history of cough, and a 1-day history of increased work of breathing. The girl had been born prematurely at 32 weeks of gestation and had a history of trisomy 21, tracheomalacia, and subglottic stenosis.

The patient had had 2 prior episodes of bronchiolitis, with normal chest radiography findings at 5 months of age in the ED.

Physical examination. On examination, the patient was in moderate distress with tachypnea and subcostal retractions. Breath sounds were equal bilaterally with diffuse wheezing. The rest of the examination findings were unremarkable.

Diagnostic tests. The patient received a clinical diagnosis of bronchiolitis and was placed on high-flow oxygen therapy via nasal cannula. Chest radiography was performed (Figures 1 and 2); the radiologist’s impression was a bowel-containing anteromedial right-sided hemidiaphragm defect, also called Morgagni hernia.

Morgagni hernia figure 1

Morgagni Hernia Figure 2
Figures 1 and 2. The radiologist’s impression was a focal opacity along the anterior and medial aspect of the right hemithorax with associated lucency, which appears contiguous with bowel on the lateral view. These findings were consistent with a bowel-containing anteromedial right hemidiaphragm defect, or Morgagni hernia.

Discussion. First described in 1761 by Giovani Morgagni, an Italian anatomist, Morgagni hernia is a rare form of congenital diaphragmatic hernia (CDH).1,2 It is also known as retrosternal or parasternal hernia and comprises less than 5% of all CDHs.2-5 It is a defect of the anterior retrosternal diaphragm and is characterized by herniation of abdominal contents through the foramen of Morgagni, a small triangular defect of the diaphragm adjacent to sternal xiphoid process.2

Although Morgagni hernia is more commonly diagnosed in children, patients can remain asymptomatic until adulthood. This condition is often diagnosed as an incidental finding on chest radiographs.2 Morgagni hernia is unique in that it is right-sided, compared with other CDHs, which are mostly left-sided.1,2 Although most patients with Morgagni hernia are asymptomatic, late presentations can be associated with chronic chest infections and nonspecific gastrointestinal tract symptoms such as vomiting and abdominal pain.1,3,5 In very rare cases, Morgagni hernia can cause significant morbidity with bowel obstruction and incarceration.2 It has a higher prevalence in patients with trisomy 21.1,3

On chest radiographs, Morgagni hernia is seen as an opacity on the anterior cardiophrenic angle, which is generally due to omentum herniating through the defect.2,4 This radiographic finding can mimic mediastinal mass, pericardial cyst, lobulated pneumothorax, right lung collapse, or lung consolidation.2 Morgagni hernia can be further confirmed by gastrointestinal contrast studies, computed tomography scans, or magnetic resonance imaging.1,2 For symptomatic patients, surgical repair provides definitive treatment.5 For asymptomatic patients, outpatient surgery referral is recommended, since the hernia may enlarge over time.2

Outcome of the case. The patient was hospitalized for 1 day on high-flow oxygen via nasal cannula for bronchiolitis and was discharged with a scheduled outpatient surgical follow-up.

REFERENCES:

  1. Jaiswal SS, Pujahari AK, Mehra R, Singh G. Congenital Morgagni hernia. Med J Armed Forces India. 2015;71(4):396-399.
  2. Nasr A, Fecteau A. Foramen of Morgagni hernia: presentation and treatment. Thorac Surg Clin. 2009;19(4):463-468.
  3. Al-Salem AH, Zamakhshary M, Al Mohaidly M, Al-Qahtani A, Abdulla MR, Naga MI. Congenital Morgagni’s hernia: a national multicenter study. J Pediatr Surg. 2014;49(4):503-507.
  4. Tirumani H, Saddala P, Fasih N. Incarcerated Morgagni hernia: an unusual cause of large bowel obstruction. J Emerg Med. 2014;47(3):320-322.
  5. Marinceu D, Loubani M, O'Grady H. Late presentation of a large Morgagni hernia in an adult. BMJ Case Rep. 2014;2014. doi:10.1136/bcr-2013-202440