Asian Cardiovasc Thorac Ann 2008;16:240-241
© 2008 Asia Publishing EXchange Ltd
Life-Threatening Vomiting Caused by Large Morgagni Hernia in an Octogenarian
Hasan Türüt, MD,
Gülen Demirpolat, MD1,
Ertan Bülbüloglu, MD2,
Mürüvvet Yüksel, MD1
Department of Thoracic Surgery
1 Department of Radiology
2 Department of General Surgery, Kahramanmaras Sutcu Imam University, School of Medicine, Kahramanmaras, Turkey
For reprint information contact: Hasan Türüt, MD, Tel: 90 344 221 2337, Fax: 90 344 221 2371, Email: drhasanturut{at}yahoo.com, Kahramanmaras Sütcü 
mam Üniversitesi, Tip Fakültesi Hastanesi Gögüs Cerrahisi Anabilim Dali, 46050, Kahramanmaras, Turkey.
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ABSTRACT
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An 84-year-old woman presented with frequent severe vomiting, dyspnea and generalized muscle weakness associated with diaphragmatic hernia. Her poor general condition and muscle weakness resembling cranial pathology were considered to be due to severe vomiting caused by a Morgagni hernia. An urgent subcostal laparotomy confirmed the diagnosis. The critical role of urgent surgery, even in advanced age, is emphasized.
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INTRODUCTION
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Morgagni hernias are rare congenital diaphragmatic hernias, and clinical experience with this entity is limited.1 As it carries a potential risk of visceral strangulation, surgical repair should be performed electively, unless otherwise indicated. Acute respiratory distress secondary to Morgagni hernia is an indication for urgent surgery.2 We describe a case of severe vomiting, which required urgent surgery.
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CASE REPORT
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An 84-year-old woman was referred to our clinic with a diagnosis of diaphragmatic hernia and a suspected cerebrovascular event. She was critically ill with dyspnea, frequent severe vomiting, nausea, generalized muscle weakness and confusion. Tachycardia, tachypnea and dehydration were detected. Her blood pressure was 74/53 mm Hg, pulse rate 122 beats·min–1, temperature 36.7°C and oxygen saturation 87%. Chest radiography showed a right-sided opacity, and computed tomography of the thorax revealed thoracal herniation of the antrum, proximal duodenum, transverse colon and omentum behind the xiphoid, passing through the right anterior paracentral defect (Figures 1
and 2). Cranial computed tomography did not reveal any indications of cerebrovascular pathology, and neurologic findings supported this. Despite nasogastric tube insertion and drainage of 2,000 mL of gastric juice, nausea and severe vomiting persisted. An urgent subcostal laparotomy revealed more than the half of the stomach had herniated through the defect and compressed the duodenum and transverse colon. The abdominal viscera were repositioned, and the diaphragmatic defect, 7 cm in size, was repaired primarily. The operation took 35 min, with no complications. The patient was transferred to the intensive care unit, and extubated 2 days after the operation. Enteral feeding was administered via a nasogastric tube for 1 week, then she started to drink and eat liquid foods. On the 12th postoperative day, while she was being fed by her family, acute asphyxia developed due to aspiration, and she died from cardiorespiratory arrest.
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Figure 1. Preoperative thoraic computed tomography revealing the antrum and body of the stomach with omentum in the right hemithorax.
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Figure 2. Reformatted image showing the stomach with air distension herniating from the foramen of Morgagni.
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DISCUSSION
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Morgagni hernias are usually detected and repaired in children, but 5% are found in adults.3 Herniation of the abdominal contents is typically caused by an increase in intraabdominal pressure secondary to trauma, pregnancy or obesity.1 In a previous series, obesity, a predisposing factor for Morgagni hernia, contributed to the symptomatology and size of the hernia. Symptoms related to the gastrointestinal tract dominate the clinical features in obese patients. On the other hand, dyspnea is the chief complaint in non-obese patients.4 Our patient was not obese but severe vomiting worsened the clinical course. In the English literature, we could not find a case of urgent operation due to severe vomiting without volvulus as a complication of Morgagni hernia, whereas there are many reports of acute respiratory symptoms or intestinal obstruction (incarceration, volvulus) requiring urgent operation.5,6
The fact that our patient was asymptomatic until advanced age was probably related to the smaller size of the abdominal viscera in the thoracic cavity, and to the absence of severe compression of the duodenum by the stomach itself. In our opinion, reduced diaphragmatic tolerance might contribute to herniation of abdominal contents into the thoracic cavity in the elderly. Thus, older patients are more likely to encounter more serious clinical features such as incarceration, acute obstruction or rarely, life-threatening vomiting as in our patient.
Management of Morgagni hernias varies; some believe there is no need to operate on asymptomatic adult patients, while is more commonly agreed that surgery is indicated as soon as the diagnosis is established because of the possibility of complications such as intestinal obstruction or incarceration.1,2,7 We strongly agree with the latter concept. Considering the fact that older patients are more likely to face serious complications, and in view of the higher morbidity rates associated with both advanced age and urgent operation, elective surgery via a transthoracic or laparoscopic approach has a critical role in asymptomatic patients with a diagnosis of Morgagni hernia. Foramen of Morgagni hernias may manifest with different clinical features, including severe vomiting without the presence of volvulus as in this case, and they may pose a challenge. Urgent operation is crucial and should be performed unreservedly, even in advanced age.
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REFERENCES
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- Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: changes in diagnosis and treatment. Ann Thorac Surg 2004;77:1956–9.[Abstract/Free Full Text]
- Kilic D, Nadir A, Doner E, Kavukcu S, Akal M, Ozdemir N, et al. Transthoracic approach in surgical management of Morgagni hernia. Eur J Cardiothorac Surg 2001;20:1016–9.[Abstract/Free Full Text]
- Barut I, Tarhan OR, Cerci C, Akdeniz Y, Bulbul M. Intestinal obstruction caused by a strangulated Morgagni hernia in an adult patient. J Thorac Imaging 2005;20:220–2.[Medline]
- Sirmali M, Turut H, Gezer S, Findik G, Kaya S, Tastepe Y, et al. Clinical and radiological evaluation of foramen of Morgagni hernias and the transthoracic approach. World J Surg 2005;29:1520–4.[Medline]
- Wong NA, Dayan CM, Virjee J, Heaton KW. Acute respiratory distress secondary to Morgagni diaphragmatic herniation in an adult. Postgrad Med J 1995;7:39–41.[Medline]
- Loong TP, Kocher HM. Clinical presentation and operative repair of hernia of Morgagni. Postgrad Med J 2005;81:41–4.[Abstract/Free Full Text]
- Bhasin DK, Nagi B, Gupta NM, Singh K. Chronic intermittent gastric volvulus within the foramen of Morgagni. Am J Gastroentrol 1989;84:1106–8.[Medline]
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ABSTRACT
INTRODUCTION
