Medical Image of the Month: Incarcerated Morgagni Hernia

Figure 1. Lateral view of abdominal-thoracic CT in soft tissue windows.

Figure 2. Coronal view of thoracic CT scan in lung windows.

A Morgagni hernia is a congenital diaphragmatic hernia in which abdominal viscera herniate into the thorax via a defect within an anterior attachment of the diaphragm. As with any bowel-containing hernia, the most feared complication is strangulation with subsequent bowel necrosis. In the present case, a 67-year-old woman presented with a five-day history of acute onset and progressively worsening upper abdominal pain and inability to tolerate oral intake, associated with nausea, vomiting, and mild shortness of breath. A CT revealed a large defect in the right hemidiaphragm consistent with a Morgagni hernia with herniation of the omentum, vessels, and a segment of transverse colon (Figure 1). Findings of bowel ischemia were observed, including (a) pneumatosis intestinalis, seen as cystic foci of air lining the bowel wall, and (b) fluid and fat-stranding adjacent to the affected bowel (Figure 2). Evidence of bowel wall perforation include large volume free air adjacent to the bowel in the right hemithorax and within the abdomen (Figures 1 and 2). Bowel ischemia and necrosis can occur with any hernia and requires prompt diagnosis and management.

Samandip Hothi MD¹ and Viral Patel MD²

¹Department of Medicine, Division of Internal Medicine and ²Department of Medical Imaging

University of Arizona College of Medicine-Tucson

Tucson, AZ USA

References

1. 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 Nov;90(8):694-5. [CrossRef] [PubMed]
2. Ly JQ. The Rigler Sign. Radiology. 2003;228(3):706-7. [CrossRef] [PubMed]
3. Morgan TB, Nguyen DN, Tran CD, Maheshwary RK, Mickus TJ. Morgagni Hernia Causing Incarcerated Bowel and Contributing to Cardiac Arrest. Curr Probl Diagn Radiol. 2018 Jul 31. pii: S0363-0188(18)30181-6. [CrossRef]

Cite as: Hothi S, Patel V. Medical image of the month: Incarcerated Morgagni hernia. Southwest J Pulm Crit Care. 2019;18:59-60. doi: https://doi.org/10.13175/swjpcc001-19 PDF 

Medical Image of the Month: Pectus Excavatum

Figure 1. A) PA chest radiograph at 38 years old demonstrates rib cage growth arrest at the time of pectus repair. B) and C) demonstrate the coronal and sagittal CT chest views.

Figure 2: Pulmonary function tests demonstrate severe restrictive ventilatory defect.

Clinical History

A 38-year-old man with obesity and history of pectus excavatum post-operative surgical repair at age 4 presented to the general pulmonary clinic with symptoms of severe dyspnea on exertion after walking one block. Chest x-ray and thoracic CT scan demonstrate anterior chest wall depression. (Figure 1). Pulmonary function testing demonstrated a severe restrictive lung disease (Figure 2).  High resolution CT demonstrated anterior chest wall depression. The Haller index was 2.5—mild excavatum—with associated scarring in the anterior right lung. Expiratory air-trapping was seen consistent with small airways disease.

Haller Index

The Haller index is calculated by dividing the transverse diameter of the chest by the anterior-posterior distance on the CT of the chest on the axial slice that demonstrates the smallest distance between the anterior surface of the vertebral body and the posterior surface of the sternum (1). Normal chest < 2.0; mild excavatum 2.0 – 3.2; moderate excavatum 3.2 – 3.5; severe excavatum > 3.5. Corrective surgery is considered for a Haller index of greater than or equal to 3.25.  Secondary thoracic dystrophy is a known consequence of too early repair of pectus excavatum (1).  Cases like our patient have changed when surgical repair is attempted until after puberty.

Michael Insel, MD and Janet Campion, MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

Banner University Medical Center-Tucson

Tucson, AZ USA

Reference

1. Haller JA Jr, Colombani PM, Humphries CT, Azizkhan RG, Loughlin GM. Chest wall constriction after too extensive and too early operations for pectus excavatum. Ann Thorac Surg. 1996 Jun;61(6):1618-24. [CrossRef] [PubMed]

Cite as: Insel M, Campion J. Medical image of the month: pectus excavatum. Southwest J Pulm Crit Care. 2019;18(2):50-1. doi: https://doi.org/10.13175/swjpcc124-18 PDF