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Morgagni hernia: CT findings
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Morgagni Hernia: CT Findings Tara B. Anthes, MD, Nisa Thoongsuwan, MD, and Riyad Karmy-Jones, MD
Case Report The patient is a 30-year-old male who presented with stabbing retrosternal chest pain, anxiety attacks, and subsequent inability to work. Chest radiograph showed an enlarged cardiac silhouette with the right heart border expanded across the right chest, suggesting a soft tissue mediastinal mass. Subsequent chest computed tomography (CT) revealed an anterior diaphragmatic defect with a large mass of mesenteric fat and peritoneal vessels protruding into the anterior mediastinum, typical of a foramen of Morgagni hernia.
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, also known as the space of Larrey.1 Larrey, Napoleon’s chief surgeon, described the anterior diaphragmatic defect, and Morgagni wrote about the hernia occurring through this defect in 1761.2 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 From the Department of Radiology, Divisions of Cardiothoracic/Trauma Surgery, Harborview Medical Center, University of Washington, Seattle, WA. Reprint requests: Riyad Karmy-Jones, MD, Department of Surgery, Box 359796, 325 Ninth Avenue, Harborview Medical Center, Seattle, WA 98104. E-mail: [email protected]. Curr Probl Diagn Radiol 2003;32:135-136. © 2003 Mosby, Inc. All rights reserved. 0363-0188/2003/$35.00 ⫹ 0 doi:10.1016/S0363-0188(02)00007-5
Curr Probl Diagn Radiol, May/June 2003
usually associated with obesity, trauma, weight lifting, or other causes of increased intraabdominal pressure.3 As in this case, findings on chest radiographs include a right-sided soft tissue density mass at the cardiophrenic angle. On chest CT scanning, a finding of a retrosternal fatty mass with omental vessels is usually pathognomonic, and superior displacement of the transverse colon is an associated finding.4 If the diagnosis is not evident after CT, magnetic resonance imaging (MRI) can be helpful for delineating a diaphragmatic defect and assisting in differentiating foramen of Morgagni hernias from other conditions that can present with a mediastinal or diaphragmatic mass. Differential diagnoses to consider with foramen of Morgagni hernia include: Epicardial Fat Pads. These can present as soft tissue masses at the cardiophrenic angle and can be confused
FIG 1. AP chest radiograph revealed a lucent, well-defined opacity in the right cardiophrenic angle (double arrows) that cannot be distinguished from a large pleuropericardial fat pad.
135
for a foramen of Morgagni hernia when located on the right. Eventration of the Diaphragm. This elevation of the diaphragm, as a result of localized muscle weakness, usually occurs on the right at the anterior diaphragm. Hiatal Hernia. Herniation of the stomach through the esophageal hiatus is usually seen as a mass at the medial left lung base, but, if large, can extend to the right. Visualization of air or fluid in the stomach protruding above the diaphragm helps confirm this etiology. Bochdalek Hernia. Herniation of bowel or fat through the pleuroperitoneal foramen of Bochdalek usually occurs posterolaterally on the left side. In adults, this is usually an incidental finding on CT scan and contains fat.5 Traumatic Diaphragmatic Rupture. Diaphragmatic rupture can occur in the setting of severe blunt trauma to the abdomen. The defect is usually left-sided with subsequent herniation of stomach, fat, and bowel.6 The clinical presentation assists in this diagnosis. Diaphragmatic tumor. These tumors are very rare. Benign tumors are usually lipomas, malignant tumors are sarcomas, most commonly fibrosarcoma. In addition to CT scanning, MRI or transabdominal ultrasound can be helpful in diagnosis.2 Large Anterior Mediastinal Masses. Large fatty anterior mediastinal masses, such as lipomas, liposarcomas, thymolipomas, and thymoliposarcomas, can be confused with a foramen of Morgagni hernia if a diaphragmatic defect is not visualized. Surgical repair of a Morgagni hernia is indicated when a patient is symptomatic, such as in this case. The patient underwent open sternotomy, reduction of the mediastinal mass, and repair of a 9-cm diaphragmatic defect of the foramen of Morgagni. Laparascopic surgery is also used commonly for repair of diaphragmatic hernias in children and symptomatic adults.
REFERENCES
FIG 2. A, B, Contrast-enhanced CT scan shows the tubular high attenuation structures (arrows) within the fat density lesion, which is compatible with omental vessels. C, Inferiorly, the diaphragmatic defect and contiguity of the omentum are noted (arrow).
136
1. Juhl JH. Paul and Juhl’s essentials of radiologic imaging, 7th ed. Baltimore: Lippincott, Williams and Wilkins, 1998. 2. Gilkeson RC, Basile V, Sands MJ, Hsu JT. Chest case of the day. AJR Am J Roentgen 1997;169:266-74. 3. Brant WE, Helms CA. Fundamentals of diagnostic radiology. Baltimore: Williams and Wilkins, 1994. 4. Eisenberg RL. Gastrointestinal radiology: a pattern approach, 3rd ed. Philadelphia: Lippencott-Raven, 1996. 5. Gale ME. Bochdalek hernia: prevalence and CT characteristics. Radiology 1985;156:449-52. 6. Worthy SA, Kang EY, Hartman TE, Kwong JS, Mayo JR, Muller NL. Diaphragmatic rupture: CT findings in 11 patients. Radiology 1995;194:885-8.
Curr Probl Diagn Radiol, May/June 2003
Morgagni Hernia: CT Findings Tara B. Anthes, MD, Nisa Thoongsuwan, MD, and Riyad Karmy-Jones, MD
Case Report The patient is a 30-year-old male who presented with stabbing retrosternal chest pain, anxiety attacks, and subsequent inability to work. Chest radiograph showed an enlarged cardiac silhouette with the right heart border expanded across the right chest, suggesting a soft tissue mediastinal mass. Subsequent chest computed tomography (CT) revealed an anterior diaphragmatic defect with a large mass of mesenteric fat and peritoneal vessels protruding into the anterior mediastinum, typical of a foramen of Morgagni hernia.
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, also known as the space of Larrey.1 Larrey, Napoleon’s chief surgeon, described the anterior diaphragmatic defect, and Morgagni wrote about the hernia occurring through this defect in 1761.2 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 From the Department of Radiology, Divisions of Cardiothoracic/Trauma Surgery, Harborview Medical Center, University of Washington, Seattle, WA. Reprint requests: Riyad Karmy-Jones, MD, Department of Surgery, Box 359796, 325 Ninth Avenue, Harborview Medical Center, Seattle, WA 98104. E-mail: [email protected]. Curr Probl Diagn Radiol 2003;32:135-136. © 2003 Mosby, Inc. All rights reserved. 0363-0188/2003/$35.00 ⫹ 0 doi:10.1016/S0363-0188(02)00007-5
Curr Probl Diagn Radiol, May/June 2003
usually associated with obesity, trauma, weight lifting, or other causes of increased intraabdominal pressure.3 As in this case, findings on chest radiographs include a right-sided soft tissue density mass at the cardiophrenic angle. On chest CT scanning, a finding of a retrosternal fatty mass with omental vessels is usually pathognomonic, and superior displacement of the transverse colon is an associated finding.4 If the diagnosis is not evident after CT, magnetic resonance imaging (MRI) can be helpful for delineating a diaphragmatic defect and assisting in differentiating foramen of Morgagni hernias from other conditions that can present with a mediastinal or diaphragmatic mass. Differential diagnoses to consider with foramen of Morgagni hernia include: Epicardial Fat Pads. These can present as soft tissue masses at the cardiophrenic angle and can be confused
FIG 1. AP chest radiograph revealed a lucent, well-defined opacity in the right cardiophrenic angle (double arrows) that cannot be distinguished from a large pleuropericardial fat pad.
135
for a foramen of Morgagni hernia when located on the right. Eventration of the Diaphragm. This elevation of the diaphragm, as a result of localized muscle weakness, usually occurs on the right at the anterior diaphragm. Hiatal Hernia. Herniation of the stomach through the esophageal hiatus is usually seen as a mass at the medial left lung base, but, if large, can extend to the right. Visualization of air or fluid in the stomach protruding above the diaphragm helps confirm this etiology. Bochdalek Hernia. Herniation of bowel or fat through the pleuroperitoneal foramen of Bochdalek usually occurs posterolaterally on the left side. In adults, this is usually an incidental finding on CT scan and contains fat.5 Traumatic Diaphragmatic Rupture. Diaphragmatic rupture can occur in the setting of severe blunt trauma to the abdomen. The defect is usually left-sided with subsequent herniation of stomach, fat, and bowel.6 The clinical presentation assists in this diagnosis. Diaphragmatic tumor. These tumors are very rare. Benign tumors are usually lipomas, malignant tumors are sarcomas, most commonly fibrosarcoma. In addition to CT scanning, MRI or transabdominal ultrasound can be helpful in diagnosis.2 Large Anterior Mediastinal Masses. Large fatty anterior mediastinal masses, such as lipomas, liposarcomas, thymolipomas, and thymoliposarcomas, can be confused with a foramen of Morgagni hernia if a diaphragmatic defect is not visualized. Surgical repair of a Morgagni hernia is indicated when a patient is symptomatic, such as in this case. The patient underwent open sternotomy, reduction of the mediastinal mass, and repair of a 9-cm diaphragmatic defect of the foramen of Morgagni. Laparascopic surgery is also used commonly for repair of diaphragmatic hernias in children and symptomatic adults.
REFERENCES
FIG 2. A, B, Contrast-enhanced CT scan shows the tubular high attenuation structures (arrows) within the fat density lesion, which is compatible with omental vessels. C, Inferiorly, the diaphragmatic defect and contiguity of the omentum are noted (arrow).
136
1. Juhl JH. Paul and Juhl’s essentials of radiologic imaging, 7th ed. Baltimore: Lippincott, Williams and Wilkins, 1998. 2. Gilkeson RC, Basile V, Sands MJ, Hsu JT. Chest case of the day. AJR Am J Roentgen 1997;169:266-74. 3. Brant WE, Helms CA. Fundamentals of diagnostic radiology. Baltimore: Williams and Wilkins, 1994. 4. Eisenberg RL. Gastrointestinal radiology: a pattern approach, 3rd ed. Philadelphia: Lippencott-Raven, 1996. 5. Gale ME. Bochdalek hernia: prevalence and CT characteristics. Radiology 1985;156:449-52. 6. Worthy SA, Kang EY, Hartman TE, Kwong JS, Mayo JR, Muller NL. Diaphragmatic rupture: CT findings in 11 patients. Radiology 1995;194:885-8.
Curr Probl Diagn Radiol, May/June 2003