Image of the quarter J R Coll Physicians Edinb 2009; 39:216–7

© 2009 Royal College of Physicians of Edinburgh

Morgagni hernia – a cause of opacification

clinical

on a chest radiograph
1
AG Wallis, 2J Arora, 3NL Bishop
1
Specialty Registrar, Radiology, University Hospitals Bristol NHS Trust; 2Consultant Radiologist, Poole Hospital NHS Foundation Trust;
3
Consultant Radiologist, University Hospitals Bristol NHS Trust, Bristol, UK

ABSTRACT Morgagni hernias are often misdiagnosed as a consolidation or collapse Published online May 2009
of the right middle lobe, and should be considered in the differential diagnosis
Correspondence to A Wallis,
of opacification at the right cardiophrenic angle. They are a form of congenital
Department of Clinical Radiology,
diaphragmatic hernia and are best demonstrated on multidetector computed Bristol Royal Infirmary,
tomography. Medical management will help alleviate gastrointestinal symptoms, but Upper Maudlin Street,
curative management is usually surgical to prevent the complication of strangulation. Bristol BS1 3NU, UK

Keywords Congenital diaphragmatic hernia, Morgagni hernia tel. +44 (0)1179 230000
e-mail [email protected]
Declaration of Interests No conflict of interests declared.

CASE REPORT
A 69-year-old woman with a medical history of breast
cancer and rheumatoid arthritis was admitted to hospital
with a short history of right upper quadrant pain.
A chest radiograph demonstrated soft tissue density at
the right cardiophrenic angle (Figure 1).The possibility of
a mass lesion was considered because of the patient’s
medical history and the lack of raised inflammatory
markers and chest symptoms. Contrast-enhanced
multislice computed tomography (CT) with multiplanar
reconstruction demonstrated a Morgagni hernia
(Figure  2). The patient was discharged and is being
considered for definitive surgery to repair the defect.

DISCUSSION Figure 1 A 69-year-old woman with a medical history

of breast cancer and rheumatoid arthritis was admitted to
Defects involving an abnormal development of the hospital with a short history of right upper quadrant pain.
A chest radiograph demonstrated opacification at the right
diaphragm are referred to as congenital diaphragmatic cardiophrenic angle.
hernias (CDH). Within this group, Bochdalek hernias,
which are most commonly left-sided and always posterior,
are the most common. Morgagni hernias represent only
3% of all diaphragmatic hernias.1 Other forms of CDH
are central tendon defects and congenital diaphragmatic
eventration. These hernias are more common in obese
patients2 and in those with other conditions that lead to
raised intra-abdominal pressure, including pregnancy,
trauma, chronic constipation and chronic cough.3

The majority of Morgagni hernias are right-sided due to

the protection afforded by the extensive pericardial
attachments to the diaphragm.4 They involve herniation
through a potential space known as the foramen of
Morgagni, which is formed as musculo-fibrotendinous
elements of the diaphragm (originating at the xiphoid
process and passing to the central tendon of the diaphragm)
fail to fuse.5 The viscus most commonly found to herniate Figure 2 Axial CT demonstrating Morgagni hernia (arrow)
at the anteromedial aspect of the right hemidiaphragm.
is the transverse colon (in 60% of patients), but the liver,

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 Morgagni hernia

mesenteric fat and, rarely, the stomach may also herniate.1 confirm the diagnosis in 100% of cases.4 Multidetector

clinical
In contrast to Bochdalek hernias, Morgagni hernias only CT with multiplanar reconstruction can play a more
rarely present with respiratory distress at birth. active role in identification of the hernia site, its level and
Recurrent chest infections and gastrointestinal symptoms the cause of any small bowel obstruction, including
such as nausea, vomiting and bloating have been reported,6 internal hernias, diaphragmatic hernias such as Morgagni
although most patients remain asymptomatic. Acute hernias and/or associated gastric volvulus.9 Computed
strangulation is a recognised complication in adults, tomography may show a contrast-filled bowel within the
with an incidence of 10–15%.7 chest or a fatty density mass, with Hounsfield units
ranging from –80 to –120. Curvilinear densities within
Most Morgagni hernias are identified incidentally on a this are likely to represent vessels within the omentum.
chest radiograph as a soft tissue density of the right
cardiophrenic angle. The appearance may be of gas- or The prevalence of Morgagni hernias has not been
fluid-filled structures in the anterior mediastinum. Other reported, and no comparison exists between surgical
diagnoses to consider are the Bochdalek hernia, right and conservative management. In adults and children
middle lobe collapse, neurofibroma, consolidation, lung surgery remains the definitive treatment modality, and is
sequestration, pericardial fat pad, lymphoma and thymic advocated due to the risk of strangulation in symptomatic
tumours.8  Where uncertainty exists, lateral chest and asymptomatic patients.10 Conservative treatment is
radiography and barium studies may help distinguish reserved for those who are otherwise unfit. Proton
between these. Patient symptoms will help to guide the pump inhibitors may provide symptomatic relief in
clinician.  A history of malignancy should not lead to the patients with a herniated stomach. Traditionally, repair
immediate conclusion of metastatic disease until imaging has been by open abdominal or thoracic approaches, but
has excluded a hernia as the cause of the mass. recent advances in minimally invasive surgery have made
the laparoscopic and thoracoscopic treatment of
Magnetic resonance imaging is able to demonstrate the Morgagni hernias possible, with rapid recovery of
hernia,5 but CT remains the investigation of choice and, patients.  A recent review gives a more detailed account
in one small retrospective study, has been shown to of the surgical management.10

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