65-year-old Lady with Right Sided Chest Pain-Interesting Radiology
Vishnukanth Govindaraj1, Jineesh Joseph2, Dharm Prakash Dwivedi3, Rajeshkumar4, Balla Nagamalli Kumar5
1 Assistant Professor, Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
2 Senior Resident, Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
3 Assistant Professor, Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
4 Senior Resident, Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
5 Senior Resident, Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Vishnukanth Govindaraj, 3, Rajaya Street, R.K. Nagar, Ariyankuppam, Puducherry-605007, India.
E-mail: vishnu1429@yahoo.com
Congenital Diaphragmatic Hernia (CDH) are known to occur in 1 in 3000 to 1 in 5000 pregnancies [1]. Three types of diaphragmatic hernia are encountered, namely bochdalek hernia, Morgagni hernia and Para Oesophageal Hiatus Hernia. Bochdalek hernia is the most common type which results from defect in the posterior part of diaphragm. Morgagni hernias result from an anterior defect and are the least common type of CDH accounting for about 5% [2]. Although congenital, delayed presentation in adults are also reported.
We present the case of a 65-year-old homemaker who presented with a six month history of right sided chest pain and dry cough. No history of trauma was reported. She denied a past history of tuberculosis and had no co-morbid illness. On examination, respiratory system examination was normal. Electrocardio gram (EKG) showed sinus rhythm. Chest X-ray demonstrated a homogenous opacity at the anterior lung base in the right cardio-phrenic sulcus and gastro oesophageal junction [Table/Fig-1]. Possibilities of right lower consolidation and diaphragmatic hernia were considered. Computed Tomography (CT) of the chest was done which showed a defect in the anterior end of right diaphragm with herniation of omentum into the right chest [Table/Fig-2]. Diagnosis of Morgagni hernia was then established.
Chest X-ray showing a homogenous opacity at the cardiophrenic angle.
CT scan showing right sided anterior herniation of omentum into the thoracic cavity.
Morgagni hernia was first described by Giovanni Battista Morgagni in 1769 [3]. It is caused by a congenital defect during the fusion of septum transversum of the future diaphragm and the costal arches. The usual location is posterolateral to the sternum. During raise of intra-abdominal pressure, the defect is accentuated resulting in herniation of intra abdominal contents. Right side is commonly involved, however left sided and bilateral involvement have also been reported. Left sided Morgagni hernia is also called Morgagni-Larrey Hernia [4].
In right sided hernia, the most common content is omentum followed by colon and small intestine whereas, stomach is the most common content in left sided hernia [5]. Pre-disposing factor for herniation like obesity, chronic cough and chronic constipation are seen in only half of the reported cases [6]. About 1/3rd of patients are asymptomatic. The most common complaints are chronic gastrointestinal symptoms like epigastric pain, fullness, substernal pain and constipation [7]. Acute presentation like complete obstruction, incarceration or strangulation of herniated viscera are less commonly encountered.
Diagnosis is established by imaging studies. On a routine chest X-ray, a pericardiophrenic opacity is usually seen. Omental herniation causes opacification and an airfluid level is seen if the content is stomach or transverse colon [3]. A Computed Tomography (CT) scan is usually the diagnostic method of choice. CT not only shows the hernia content but also the location of the defect [8].
Roentgenological differential diagnosis includes right middle lobe collapse, neurolipoma, consolidation, lung sequestration, pericardial fat pad, lymphoma and thymic tumour [9].
Treatment is usually surgical to avoid potential incarceration and strangulation. Repair via trans-thoracic or trans abdominal approach are performed. Minimally invasive laprascopic approach or video assisted thoracoscopic approach are also performed [4].
[1]. Puri P, Epidemiology of congenital diaphragmatic hernia Mod Probl Paediatr 1989 24:22-27. [Google Scholar]
[2]. Nawaz A, Matta H, Jacobsz A, Al-Khouder G, Al-Salem AH, Congenital Morgagni’s hernia in infants and children Int Surg 2000 85:158-62. [Google Scholar]
[3]. Loong TPF, Kocher HM, Clinical presentation and operative repair of hernia of Morgagni Postgrad Med J 2005 81:41-44. [Google Scholar]
[4]. Pattnaik MK, Sahoo SP, Panigrahy SK, Nayak KB, Morgagni hernia: A rare case report and review of literature Lung India 2016 33:427-29. [Google Scholar]
[5]. Abraham V, Myla Y, Verghese S, Chandran BS, Morgagni-Larrey hernia – A review of 20 cases Indian J Surg 2012 74:391-95. [Google Scholar]
[6]. Aghajanzadeh M, Khadem S, KhajehJahromi S, Gorabi HE, Ebrahimi H, Maafi AA, Clinical presentation and operative repair of Morgagni hernia Interact Cardiovasc Thorac Surg 2012 15:608-11. [Google Scholar]
[7]. Berardi R, Tenquist J, Sauter D, An update on the surgical aspects of Morgagni’s hernia Surgical Rounds 1997 :370-76. [Google Scholar]
[8]. Minneci PC, Deans KJ, Kim P, Mathisen DJ, Foramen of Morgagni hernia: Changes in diagnosis and treatment Ann Thorac Surg 2004 77:1956-59. [Google Scholar]
[9]. Pineda V, Andreu J, Cáceres J, Merino X, Varona D, Domínguez Oronoz R, Lesions of the cardiophrenic space: Findings at cross-sectional imaging Radiographics 2007 27:19-32. [Google Scholar]