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

Discussion

Morgagni hernia, representing about 3% of all surgically repaired diaphragmatic hernias, was first described by Italian anatomist and pathologist Giovanni Morgagni in 1769. Although the anterior diaphragmatic defect is considered congenital, Morgagni hernia very uncommonly presents during the neonate period or in childhood.[3] The reason for the latter may be the requirement of increased intra-abdominal pressure with age to stretch the defect.[4] The hernia is usually found on the right side[5] and rarely on the left. Bilateral presentations are extremely rare.[6] Most patients with Morgagni hernia are diagnosed and treated before age 50.[5] Our patient was diagnosed at the atypical age of 91 years.

Approximately 50% to 70% of patients are asymptomatic and are diagnosed during investigation for other unrelated problems.[5] Symptoms, when they do occur, include respiratory or cardiovascular complaints such as shortness of breath, and gastrointestinal symptoms such as nausea, vomiting, abdominal discomfort, anorexia, or, rarely, complications such as gastric volvulus,[3,7] gastric outlet obstruction,[8] or incarcerated bowel.[4] Our patient presented with chronic intermittent nausea and vomiting. Her presentation was complicated by acute upper gastrointestinal bleeding and sepsis, raising the suspicion that the hernia became strangulated and ischemic.

The most common Morgagni hernia contents are omentum and colon[5]; less frequently found are stomach, liver, or small intestine. Diagnosis can be made by plain chest or abdominal x-ray, barium studies (upper gastrointestinal series, small bowel studies, or barium enema, depending on the herniated organs), or even by ultrasound examination.[2] Recently, CT scans have become the diagnostic method of choice, making the correct diagnosis in 100% of cases in a recent series.[5] Congested blood vessels[3] and gastric volvulus may be seen, if present, during endoscopy. Endoscopy is generally not helpful in diagnosis. In our patient, diagnosis was made by plain x-ray and confirmed by CT scan; the CT scan also helped identify the specific herniated organs. Upper endoscopy was not diagnostic in our patient, but the inability to pass the endoscope beyond the duodenal bulb suggested some gastric anomaly. A normal anatomy during upper endoscopy performed 3 years ago in our patient suggested that Morgagni hernia of the stomach was either an interim development or was just simply intermittent, with the stomach sliding in and out of the chest.

Surgical repair of the diaphragmatic defect in a timely fashion is recommended because complications such as hernia incarceration, bowel obstruction, strangulation, or gastric volvulus can occur.

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