Do not miss the forest for the trees – Clinicoradiological quiz

Nitesh Gupta; Arul J Mahendran; Neeraj Kumar Gupta; Pranav Ish

doi:10.4103/jalh.jalh_2_22

POSTGRADUATE FORUM

Year : 2022 | Volume : 2 | Issue : 2 | Page : 75-77

Do not miss the forest for the trees – Clinicoradiological quiz

Nitesh Gupta, Arul J Mahendran, Neeraj Kumar Gupta, Pranav Ish
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission	02-Feb-2022
Date of Acceptance	13-Feb-2022
Date of Web Publication	17-May-2022

Correspondence Address:
Dr. Pranav Ish
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, Room Number 638, Super Speciality Block, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jalh.jalh_2_22

Abstract

Abstract-Right hypochondrium pain with air-fluid level in chest X-ray can have a long list of differential diagnosis. A meticulous evaluation of history with appropriate investigations can help make the correct diagnosis.

Keywords: Air-fluid level, morgagni hernia, radiology

How to cite this article:
Gupta N, Mahendran AJ, Gupta NK, Ish P. Do not miss the forest for the trees – Clinicoradiological quiz. J Adv Lung Health 2022;2:75-7

How to cite this URL:
Gupta N, Mahendran AJ, Gupta NK, Ish P. Do not miss the forest for the trees – Clinicoradiological quiz. J Adv Lung Health [serial online] 2022 [cited 2023 Jun 11];2:75-7. Available from: https://www.jalh.org//text.asp?2022/2/2/75/345375

Case

A 58-year-old female, with no prior comorbidities, presented with a history of abdominal pain. The pain was localized in the right hypochondrium, was gradual in onset, dull aching, referred to the right shoulder, and associated with nausea and dyspepsia for 3–5 days with no specific exacerbating or relieving factor. There was a history of similar episodes of abdominal pain in the past which resolved with antacids. Ultrasound abdomen revealed the presence of gallstones with no evidence of active inflammation. A possible diagnosis of cholelithiasis with resolved cholecystitis was made, and the patient was planned for interval laparoscopic cholecystectomy.

On examination of the patient, the body mass index was 30.6 kg/m², blood pressure was 110/70 mmHg, pulse rate was 82 per min, respiratory rate was 18 per min, and saturation oxygen was 98%. The physical examination of the abdomen was noncontributory with no tenderness or palpable mass. Respiratory system examination revealed reduced air entry in the right inter- and infrascapular regions. The other systemic examination was normal. The chest X-ray [Figure 1] showed right-sided homogenous opacity with an air-fluid level, silhouetting the diaphragm, and right heart border.

Figure 1: Chest X-ray P/A view showing right-sided homogenous opacity silhouetting the diaphragm and right heart border with an air-fluid level

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Question: What is the possible diagnosis?

Answer:

Differential diagnosis on the basis of the X-ray included the following

Pulmonary differentials

Cavity with air-fluid level
Lung abscess
Infected bronchogenic cyst
Subpulmonic loculated empyema.

Extrapulmonary intrathoracic differentials

Pericardial cyst
Dilatation of esophagus-hiatus hernia/achalasia cardia.

Extrathoracic differentials

Liver abscess with or without rupture
Subdiaphragmatic abscess
Diaphragmatic hernia
Diaphragmatic eventration.

Question: How do you confirm the diagnosis.

Answer: Computed tomography (CT) chest.

CT of the chest was performed [Figure 2]a and [Figure 2]b to reveal the nature of the opacity. CT scan showed the presence of loops of the large intestine and fat that herniated through the defect in right diaphragm, replacing the right lung in the chest. A diagnosis of right-sided Morgagni hernia was established. This could explain the intermittent right hypochondrial pain along with the referred pain to the shoulder due to the irritation of right diaphragm, all mimicking cholecystitis.

Figure 2: Computed tomography scan of the chest (a and b) showing the presence of loops of the large intestine and fat herniated through the defect in right diaphragm

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Discussion

Diaphragmatic hernias are rare congenital anomalies which may present as any of four types – Bochdalek hernia (posterolateral), hiatal hernia (through esophageal hiatus), paraesophageal hernia, and Morgagni hernia. Morgagni hernia is anterior in location, and the patients often present with minimal and nonspecific symptoms such as dyspepsia, abdominal pain, and nausea.^[1] It is uncommonly associated with pulmonary hypoplasia (unlike Bochdalek hernia), and hence, childhood diagnosis is often missed as respiratory distress and recurrent respiratory infections are rare. This leads to underestimation of the true prevalence; however, the literature suggests that Morgagni hernia contributes 2%–5% of all congenital diaphragmatic hernias.^[2] It is often right-sided, as also seen in our case, because of the pericardial support to the left side of the diaphragm.^[3]

Morgagni hernia has a defect in the diaphragm which increases with age due to an increase in intra-abdominal pressure leading to herniation of abdominal structures – large intestine (most common), omentum, and sometimes, even stomach and small intestine. Thus, any factor that leads to increase in intra-abdominal pressure including cough, lifting weights, pregnancy, constipation, and trauma can precipitate herniation and abdominal symptoms.^[4]

Diagnosis of Morgagni hernia is radiological. Chest X-ray anteroposterior and lateral films can help to identify retrosternal radiolucent shadows. CT scan is confirmatory and often obviates the need of barium meal or enema. As there is always a risk of bowel obstruction, volvulus, and incarceration, surgical correction is the treatment of choice for all such patients. Surgical correction is done through thoracic or abdominal approach and it is often curative with very low recurrence rates.^[5]

To conclude, in the current case, the congenital diaphragmatic hernia was missed as a cause of right hypochondrium pain with referred pain in the right shoulder. The surgical team diagnosed the case as gallstone-associated cholecystitis as it is endemic in the Gangetic belt, especially in middle-aged females who are obese.^[6] However, it is a learning experience to consider all possible differentials when the available investigations do not explain a clinical sign without proceeding with assumptions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Papanikolaou V, Giakoustidis D, Margari P, Ouzounidis N, Antoniadis N, Giakoustidis A, et al. Bilateral morgagni hernia: Primary repair without a mesh. Case Rep Gastroenterol 2008;2:232-7.
2.	Garriboli M, Bishay M, Kiely EM, Drake DP, Curry JI, Cross KM, et al. Recurrence rate of Morgagni diaphragmatic hernia following laparoscopic repair. Pediatr Surg Int 2013;29:185-9.
3.	Mohamed M, Al-Hillan A, Shah J, Zurkovsky E, Asif A, Hossain M. Symptomatic congenital Morgagni hernia presenting as a chest pain: A case report. J Med Case Rep 2020;14:13.
4.	Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: Changes in diagnosis and treatment. Ann Thorac Surg 2004;77:1956-9.
5.	Escarcega P, Riquelme MA, Lopez S, González AD, Leon VY, Garcia LR, et al. Multi-institution case series of pediatric patients with laparoscopic repair of Morgagni hernia. J Laparoendosc Adv Surg Tech A 2018;28:1019-22.
6.	Madhawi R, Pandey A, Raj S, Mandal M, Devi S, Sinha PK, et al. Geographical pattern of carcinoma gallbladder in Bihar and its association with river Ganges and arsenic levels: Retrospective individual consecutive patient data from Regional Cancer Centre. South Asian J Cancer 2018;7:167-70. [PUBMED] [Full text]