SESSION TITLE: Miscellaneous Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Morgagni’s hernia is the most rare of the four types of congenital Diaphragmatic hernia (CDH). More than half number of cases are incidental. We report a case of a 13 year old girl with history of shortness of breath since childhood relieved with bronchodilators and incidentally found to have Morgagni’s hernia.
CASE PRESENTATION: A Girl aged 13 years presented with dyspnea and cough for 15 days.History of repeated attacks of shortness of breath since the age of three with nocturnal exacerbations and relieved with bronchodilators but with no family history of shortness of breath.Clinically,on auscultation there was diminished breath sounds in right mammary area and bilateral diffuse rhonchi. Complete blood count and renal function tests were within normal limit.Spirometry revealed obstructive pattern with reversibility of FEV1 >12%.Chest x ray incidentally revealed right mid zone opacity further on CT scan of chest and upper abdomen and Barium meal follow confirmed the final diagnosis of Morgnani’s hernia and patient was posted for laparoscopic surgery. Prosthetic mesh was used to close the defect.Child is well on follow up inhaler therapy was advised for 6 months for asthma but after 6 months child was weaned off the inhaler therapy and is completely doing well without any further exacerbation or for any further use of inhaler therapy.
DISCUSSION: The most common type of CDH is Bochdalek hernia (posterolateral defect) which manifests itself soon after birth. The other type of CDH is Morgagni hernia (retrosternal hernia) which occurs due to development defect caused by failure of fusion between the fibrotendinous elements of sternal and costal portion of the diaphragm.The symptoms of Morgagni hernia usually do not become apparent until attainment of adulthood, usually after 50 years of age. In younger age group it occurs predominantly in males; however, among the elderly it predominates in female. This hernia is rare in children, representing only 1%-6% of all types of CDH . The reason behind rarity among the children may be that increased intra-abdominal pressure with advancing age is require to stretch the defect and cause herniation of abdominal content in to thorax . The diagnosis of this hernia is often delayed because most of the patients are asymptomatic; presence of hernia is detected only incidentally on chest X-ray . If symptomatic, it produces variable nonspecific respiratory or gastrointestinal symptoms but rarely acute intestinal obstruction and colonic perforation as presenting features have been reported.The transverse colon or omentum is the usual content of this hernia; stomach or portions of the liver are rare. After diagnosis all cases should be operated to avoid the risk of bowel strangulation and perforation.
CONCLUSIONS: In this patient initially the diagnosis was missed as there was presence of bilateral diffuse rhonchii and reversibility on spirometry but incidentally on chest x ray and further on CT scan diagnosis was confirmed that led to proper management in this case and preventing from occurrence of catastrophic events like strangulation and perforation. This again infers the importance of simple investigational procedures like chest x ray.
Reference #1: Cullen ML, Klein MD, Philippart AI. Congenital diaphragmatic hernia. Surg Clin North Am. 1985;65: 1135-8.
Reference #2: Loong TPF, Kocher HM. Clinical presentation and operative repair of hernia of Morgagni. Postgrad Med J. 2005;81:41-4.
Reference #3: Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: changes in diagnosis and treatment.Ann Thorac Surg. 2004;77:1956-9.
DISCLOSURE: The following authors have nothing to disclose: Niranjan Ananda setty, Srijay Patnaik, Jyoti Patnaik, Thitta Mohanty, Amith Sreedharan
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