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Morgagni-type Diaphragmatic Hernia Presenting as an Abnormal Cardiac Silhouette
CLINICAL COMMUNICATION TO THE EDITOR
Morgagni-type Diaphragmatic Hernia Presenting as an Abnormal Cardiac Silhouette To the Editor: A previously healthy 28-year-old woman presented to the Emergency Department with new onset of diabetes mellitus complicated by diabetic ketoacidosis. Posteroanterior chest radiograph (Figure 1) showed a large “mass” without silhouette sign along the right cardiac border. Bowel sounds were audible to auscultation of the right second intercostal space. After resolution of diabetic ketoacidosis, contrast-enhanced multislice computed tomography of the chest (Figure 2) showed a large Morgagni-type diaphragmatic hernia without strangulation. The patient had an uncomplicated laparoscopic repair of the diaphragmatic hernia with mesh placement.
Funding: There was no funding for this article. Conflict of Interest: All authors have nothing to disclose that is relevant to this manuscript. Authorship: All authors had access to the data. All authors had a role in writing the manuscript, have read the manuscript, and agree with its content. Requests for reprints should be addressed to Shahbudin H. Rahimtoola, MB, DSc (Hon), University of Southern California, 1200 N. State Street, Old GNH 7131, Los Angeles, CA 90033. E-mail address: [email protected]
Figure 1 Posteroanterior (PA) chest radiograph showing a large mass along the right cardiac silhouette.
0002-9343/$ -see front matter © 2010 Elsevier Inc. All rights reserved.
Figure 2 Contrast-enhanced multislice computed tomography of the chest showing a Morgagni-type diaphragmatic hernia extending to the level of the pulmonary artery bifurcation.
Differential diagnosis of a shadow along the right cardiac border includes right atrial enlargement due to Ebstein anomaly or mitral stenosis, pulmonary sequestration, pericardial cyst, mediastinal mass, and diaphragmatic hernias. Diaphragmatic hernias are rare congenital conditions, which may remain asymptomatic until adulthood. Morgagni-type diaphragmatic hernias account for approximately 2% of all congenital diaphragmatic hernias.1 They develop due to lack of fusion between the sternal and crural portions of the diaphragm during the 7th week of gestation. The majority of adults present with symptoms related to the hernia. The most common presenting symptoms are pulmonary complaints, chest pain or pressure, and gastrointestinal obstruction. Patients may present with life-threatening conditions such as bowel incarceration or peritonitis, the incidence of which is 10%-15%.2 The most common viscus to herniate is the transverse colon, but the liver, mesentery or, rarely, the stomach may also be involved. Laparoscopic surgical repair can be performed with little morbidity or mortality and is recommended in asymptomatic patients to avoid future complications.3 Samuel Daneshvar, MDa Jabi Shriki, MDb Helen Sohn, MDc Shahbudin H. Rahimtoola, MB, DSc (Hon)a a
Division of Cardiology
e12
The American Journal of Medicine, Vol 123, No 10, October 2010 b
Department of Clinical Radiology c Department of Clinical Surgery Department of Medicine Griffith Center LAC⫹USC Medical Center Keck School of Medicine University of Southern California Los Angeles, Calif.
doi:10.1016/j.amjmed.2010.03.034
References 1. Torfs CP, Curry CJ, Bateson TF, Honoré LH. A population-based study of congenital diaphragmatic hernia. Teratology. 1992;46:555565. 2. Arora S, Haji A, Ng P. Adult Morgagni hernia: the need for clinical awareness, early diagnosis and prompt surgical intervention. Ann R Coll Surg Engl. 2008;90:694-695. 3. Durak E, Gur S, Cokmez A, Atahan K, Zahtz E, Tarcan E. Laparoscopic repair of Morgagni hernia. Hernia. 2007;11:265-270.
Morgagni-type Diaphragmatic Hernia Presenting as an Abnormal Cardiac Silhouette To the Editor: A previously healthy 28-year-old woman presented to the Emergency Department with new onset of diabetes mellitus complicated by diabetic ketoacidosis. Posteroanterior chest radiograph (Figure 1) showed a large “mass” without silhouette sign along the right cardiac border. Bowel sounds were audible to auscultation of the right second intercostal space. After resolution of diabetic ketoacidosis, contrast-enhanced multislice computed tomography of the chest (Figure 2) showed a large Morgagni-type diaphragmatic hernia without strangulation. The patient had an uncomplicated laparoscopic repair of the diaphragmatic hernia with mesh placement.
Funding: There was no funding for this article. Conflict of Interest: All authors have nothing to disclose that is relevant to this manuscript. Authorship: All authors had access to the data. All authors had a role in writing the manuscript, have read the manuscript, and agree with its content. Requests for reprints should be addressed to Shahbudin H. Rahimtoola, MB, DSc (Hon), University of Southern California, 1200 N. State Street, Old GNH 7131, Los Angeles, CA 90033. E-mail address: [email protected]
Figure 1 Posteroanterior (PA) chest radiograph showing a large mass along the right cardiac silhouette.
0002-9343/$ -see front matter © 2010 Elsevier Inc. All rights reserved.
Figure 2 Contrast-enhanced multislice computed tomography of the chest showing a Morgagni-type diaphragmatic hernia extending to the level of the pulmonary artery bifurcation.
Differential diagnosis of a shadow along the right cardiac border includes right atrial enlargement due to Ebstein anomaly or mitral stenosis, pulmonary sequestration, pericardial cyst, mediastinal mass, and diaphragmatic hernias. Diaphragmatic hernias are rare congenital conditions, which may remain asymptomatic until adulthood. Morgagni-type diaphragmatic hernias account for approximately 2% of all congenital diaphragmatic hernias.1 They develop due to lack of fusion between the sternal and crural portions of the diaphragm during the 7th week of gestation. The majority of adults present with symptoms related to the hernia. The most common presenting symptoms are pulmonary complaints, chest pain or pressure, and gastrointestinal obstruction. Patients may present with life-threatening conditions such as bowel incarceration or peritonitis, the incidence of which is 10%-15%.2 The most common viscus to herniate is the transverse colon, but the liver, mesentery or, rarely, the stomach may also be involved. Laparoscopic surgical repair can be performed with little morbidity or mortality and is recommended in asymptomatic patients to avoid future complications.3 Samuel Daneshvar, MDa Jabi Shriki, MDb Helen Sohn, MDc Shahbudin H. Rahimtoola, MB, DSc (Hon)a a
Division of Cardiology
e12
The American Journal of Medicine, Vol 123, No 10, October 2010 b
Department of Clinical Radiology c Department of Clinical Surgery Department of Medicine Griffith Center LAC⫹USC Medical Center Keck School of Medicine University of Southern California Los Angeles, Calif.
doi:10.1016/j.amjmed.2010.03.034
References 1. Torfs CP, Curry CJ, Bateson TF, Honoré LH. A population-based study of congenital diaphragmatic hernia. Teratology. 1992;46:555565. 2. Arora S, Haji A, Ng P. Adult Morgagni hernia: the need for clinical awareness, early diagnosis and prompt surgical intervention. Ann R Coll Surg Engl. 2008;90:694-695. 3. Durak E, Gur S, Cokmez A, Atahan K, Zahtz E, Tarcan E. Laparoscopic repair of Morgagni hernia. Hernia. 2007;11:265-270.