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Right Cardiophrenic Angle Mass
Electronic Clinical Challenges and Images in GI Right Cardiophrenic Angle Mass
Question: A 51-year-old woman underwent routine chest radiography. Posterior-anterior chest radiography showed a smooth, well-circumscribed soft tissue density mass in the right cardiophrenic angle that measured 5 cm in diameter and rendered the right cardiophrenic angle opaque (Figure A, arrow). The lateral view identified the anterior position of the mass (Figure B, arrow). The patient had no significant past medical history. She denied any weight loss, nausea, vomiting, or abdominal pain. Physical examination revealed stable vital signs and laboratory examinations were unremarkable. A contrast-enhanced computed tomography (CT; Figure C) was performed to confirm the suspected diagnosis. What is the diagnosis?
See the GASTROENTEROLOGY web site (www.gastrojournal. org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. PIETRO SEDATI, MD BRUNO BEOMONTE ZOBEL, MD Department of Radiology University of Rome Campus Bio-Medico LUCIO SANNINO, MD Department of Gastroenterology Casa di Cura Sanatrix Rome, Italy Conflicts of interest The authors disclose no conflicts. © 2010 by the AGA Institute 0016-5085/10/$36.00 doi:10.1053/j.gastro.2009.05.048
GASTROENTEROLOGY 2010;138:e9 — e10
e10
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 138, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 5: Morgagni’s Hernia On the basis of chest radiography (Figure A and B) as part of the differential diagnosis, the possibility of a large pericardial fat pad or a Morgagni’s hernia was considered, but the presence of lymphoma or a middle-lobe atelectasis, even though considered less probable, could not be excluded with certainty. Axial contrast-enhanced CT (Figure C) demonstrated a large, nonenhancing mass located in the right cardiophrenic angle. The density measured in the region of interest (white circle, ⫺135 Hounsfield units) is consistent with fat. Coronal (Figure D) and axial (Figure E) CT multiplanar reconstructions demonstrated the connection of the mass to the omental fat through a small defect in the anteromedial portion of the diaphragm (curved arrows). Moreover, there are several omental vessels coursing through the fat mass (Figure D, small arrows) and some atelectasis of the right lower lobe (Figure D, open arrow). The findings are consistent with a Morgagni’s hernia. The hernia that now bears his name was first described by Morgagni after reading an autopsy of an Italian stonecutter and published in his book Seats and Causes of Diseases (1761).1 This defect also is referred to as the space of Larrey, Napoleon’s surgeon, who described the retrosternal space as an avenue through which pericardial tamponade could be treated.2 Morgagni hernias are uncommon, accounting for only 1%–3% of hernias.3 They are usually small, anteromedial, parasternal defects caused by maldevelopment of the septum transversum. They occur on the right much more than the left because the left foramen is protected by the pericardium. The most common herniated structures include omental fat, transverse colon, and liver. They are often associated with a pericardial deficiency and organs/fat may herniate up into the pericardial sac or the heart may herniate inferiorly into the abdomen. Patients are usually asymptomatic, but occasionally complain of retrosternal pain, gastrointestinal, or respiratory symptoms. Strangulation of hernial contents reportedly occurs in 10%–15% of cases. Because of its congenital nature, Morgagni hernia often is considered to be a pediatric condition and could be considered a rare clinical entity among adults without a well-described prevalence or natural history. The clinical presentation of this hernia may be confusing, and definitive management strategies have not been well established. References 1. Hoffmann KF, Chilko J. Subcostosternal diaphragmatic hernia. Ann Intern Med 1954;41:616 – 629. 2. Comer TP, Schmalhorst WR, Arbegast NR. Foramen of Morgagni hernia diagnosed by liver scan. Chest 1973;63:1036 –1038. 3. Catalona WJ, Crowder WL, Chretien PB. Occurrence of hernia of Morgagni with filial cervical lung hernia: a hereditary defect of the cervical mesenchyme? Chest 1972;62:340 –342. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Question: A 51-year-old woman underwent routine chest radiography. Posterior-anterior chest radiography showed a smooth, well-circumscribed soft tissue density mass in the right cardiophrenic angle that measured 5 cm in diameter and rendered the right cardiophrenic angle opaque (Figure A, arrow). The lateral view identified the anterior position of the mass (Figure B, arrow). The patient had no significant past medical history. She denied any weight loss, nausea, vomiting, or abdominal pain. Physical examination revealed stable vital signs and laboratory examinations were unremarkable. A contrast-enhanced computed tomography (CT; Figure C) was performed to confirm the suspected diagnosis. What is the diagnosis?
See the GASTROENTEROLOGY web site (www.gastrojournal. org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. PIETRO SEDATI, MD BRUNO BEOMONTE ZOBEL, MD Department of Radiology University of Rome Campus Bio-Medico LUCIO SANNINO, MD Department of Gastroenterology Casa di Cura Sanatrix Rome, Italy Conflicts of interest The authors disclose no conflicts. © 2010 by the AGA Institute 0016-5085/10/$36.00 doi:10.1053/j.gastro.2009.05.048
GASTROENTEROLOGY 2010;138:e9 — e10
e10
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 138, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 5: Morgagni’s Hernia On the basis of chest radiography (Figure A and B) as part of the differential diagnosis, the possibility of a large pericardial fat pad or a Morgagni’s hernia was considered, but the presence of lymphoma or a middle-lobe atelectasis, even though considered less probable, could not be excluded with certainty. Axial contrast-enhanced CT (Figure C) demonstrated a large, nonenhancing mass located in the right cardiophrenic angle. The density measured in the region of interest (white circle, ⫺135 Hounsfield units) is consistent with fat. Coronal (Figure D) and axial (Figure E) CT multiplanar reconstructions demonstrated the connection of the mass to the omental fat through a small defect in the anteromedial portion of the diaphragm (curved arrows). Moreover, there are several omental vessels coursing through the fat mass (Figure D, small arrows) and some atelectasis of the right lower lobe (Figure D, open arrow). The findings are consistent with a Morgagni’s hernia. The hernia that now bears his name was first described by Morgagni after reading an autopsy of an Italian stonecutter and published in his book Seats and Causes of Diseases (1761).1 This defect also is referred to as the space of Larrey, Napoleon’s surgeon, who described the retrosternal space as an avenue through which pericardial tamponade could be treated.2 Morgagni hernias are uncommon, accounting for only 1%–3% of hernias.3 They are usually small, anteromedial, parasternal defects caused by maldevelopment of the septum transversum. They occur on the right much more than the left because the left foramen is protected by the pericardium. The most common herniated structures include omental fat, transverse colon, and liver. They are often associated with a pericardial deficiency and organs/fat may herniate up into the pericardial sac or the heart may herniate inferiorly into the abdomen. Patients are usually asymptomatic, but occasionally complain of retrosternal pain, gastrointestinal, or respiratory symptoms. Strangulation of hernial contents reportedly occurs in 10%–15% of cases. Because of its congenital nature, Morgagni hernia often is considered to be a pediatric condition and could be considered a rare clinical entity among adults without a well-described prevalence or natural history. The clinical presentation of this hernia may be confusing, and definitive management strategies have not been well established. References 1. Hoffmann KF, Chilko J. Subcostosternal diaphragmatic hernia. Ann Intern Med 1954;41:616 – 629. 2. Comer TP, Schmalhorst WR, Arbegast NR. Foramen of Morgagni hernia diagnosed by liver scan. Chest 1973;63:1036 –1038. 3. Catalona WJ, Crowder WL, Chretien PB. Occurrence of hernia of Morgagni with filial cervical lung hernia: a hereditary defect of the cervical mesenchyme? Chest 1972;62:340 –342. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).