Gastroduodenal Obstruction From Morgagni Hernia in an Elderly Patient

Laura Borodyansky Dodis, MD; Michael William Bennett, MD, MB BCh BAO, PhD, MRCPI; David L. Carr-Locke, MD, FRCPSeries Editor: David L. Carr-Locke, MD, FRCP

Disclosures

December 15, 2005

Case Report

A 91-year-old white female nursing home resident with chronic intermittent nausea and vomiting presented to the emergency department with an episode of nausea and vomiting of 3 days' duration. She reported vomiting 5-6 times per day. The vomitus was composed initially of food residues, then brownish fluids, and was not bilious or bloody. She had associated epigastric discomfort, which was partially relieved by vomiting. Her last bowel movement was 5 days ago, but she did continue to pass flatus. The intermittent episodes of nausea and vomiting started about 2 years prior to presentation, occurring every 2-3 months; emesis was bilious at times during these past episodes. There were no clear precipitating factors. Previous work-ups included an upper endoscopy performed 6 months ago that showed a "U-shaped" stomach (Figure 1); the endoscope could not be advanced beyond the bulb. Her past gastrointestinal history included duodenal bulb ulcer secondary to nonsteroidal anti-inflammatory drug use 3 years ago, when an upper endoscopy was performed and advanced to the second portion of the duodenum. Her past medical history was significant for coronary artery disease, congestive heart failure, peripheral vascular disease, and ascending aortic aneurysm. There was no history of abdominal surgery or trauma.

Upper endoscopy performed 6 months prior to presentation showing "U-shaped" stomach.

Physical exam revealed an elderly frail woman with stable vital signs. Her mucous membrane was dry. There were decreased breath sounds at the right lung base. Her abdomen was mildly distended, and bowel sounds were present. There was mild epigastric tenderness without rebound or guarding. Digital rectal exam showed that the rectal vault was empty.

Results of laboratory studies were significant for an elevated blood urea nitrogen of 46 mg/dL and creatinine of 2.8 mg/dL. Blood carbon dioxide level was marginally increased at 31 mEq/L, with chloride low at 90 mEq/L -- findings all consistent with a history of vomiting. There was also mild leukocytosis. Her serum amylase, lipase, and cardiac enzymes were normal. Abdominal x-ray showed a dilated stomach, with the distal stomach high in the chest, and distended large and small bowel without air fluid levels or free air (Figure 2).

Abdominal x-ray showing distended stomach, with distal stomach displaced high in chest.

Chest x-ray showed a gas-filled hollow structure in the right chest; lateral film revealed the structure was at the anterior chest with air fluid level (Figures 3a, 3b). CT scan of the abdomen confirmed an anterior diaphragmatic hernia (Morgagni hernia) containing the stomach (Figures 4a-4c). The small bowel was decompressed, consistent with gastroduodenal obstruction. No gastric volvulus was seen on CT scan.

Chest x-ray showing gas-filled structure in right thoracic cavity.

Lateral chest x-ray showing the gas-filled structure at anterior chest.

Scout film prior to abdominal CT scan showing herniated stomach into chest.

CT scan showing herniated stomach.

CT scan showing herniated stomach at a lower cut.

The patient was treated with nasogastric tube (NGT) suction, with aspiration of a large quantity of brownish fluid. Her clinical course improved. Surgical repair was recommended but was declined by the patient. She later developed a large amount of bloody NGT output, with a decrease in blood count. However, the patient and family refused upper endoscopy, surgery, or any other invasive measures. She was transfused with several units of blood. Upper gastrointestinal bleeding eventually ceased, but unfortunately the patient then developed septic shock and chose comfort care only.

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