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 Week: Renal Infarction

Figure 1. Contrast enhanced CT of the abdomen showing the majority of the right kidney infarcted with some preservation of the superior pole. 

A 79-year-old woman with past medical history of persistent atrial fibrillation not on anticoagulation, coronary artery disease, hypertension, diabetes, and hyperlipidemia presented with right flank pain accompanied by nausea and vomiting for two days. Laboratory studies showed leukocytosis with creatinine of 1.2. Urinalysis was negative for signs of infection and red blood cells. However, despite being on analgesic, she continued to have flank pain. The patient subsequent underwent CT scan of the abdomen and pelvis the next day, which showed that the majority of the right kidney was infarcted. Interestingly, there were two right-sided renal arteries and a thrombus was seen in the inferior main right renal artery. The superior pole of the right kidney was preserved as a result of the patent accessory renal artery. Due to delayed presentation of more than 48 hours after onset of pain, the tissue could not be re-vascularized by vascular surgery. Her renal function remained intact and her flank pain gradually improved. 

Acute renal infarction is difficult to diagnose as it is mimicked by more commonly seen causes such as pyelonephritis and nephrolithiasis. Pain in the unilateral flank and/or abdomen is the hallmark presenting feature, however nausea, vomiting, and fever are also common. New or increasingly severe hypertension is found in approximately half of acute renal infarction diagnosis, a sign that should raise clinical suspicion in similar clinical scenario. Proteinuria is another feature that may be present on urinalysis. Creatinine elevation consistent with acute kidney injury (AKI) occurs in approximately 30-40% of cases (1). Leukocytosis is commonly seen in as many as three-quarters of patients with renal infarct. The most common laboratory finding in renal infarction is elevation of LDH, although this is nonspecific and does not necessarily aid in specific diagnosis (2). Diagnosis is usually made through contrast enhanced CT abdomen, however angiography may also be used.

Our patient also had two renal arteries supplying her right kidney, allowing for the superior pole of her renal parenchyma to be spared and thus her kidney function. The kidney tolerates ischemia for approximately 12 hours, making early diagnosis paramount. In patient’s such as the one described here that involves all or majority of one kidney, embolectomy is recommended because of favorable outcomes in prior studies (3). In summary, the challenge of early diagnosis of renal infarction lies in the recognition of nonspecific clinical symptoms and signs in an already rare occurrence. Recognizing these signs within hours of presentation may be the difference between viable renal tissue and death of a kidney. Keeping a high suspicion in patients with atrial fibrillation will also aid in early diagnosis.

Jessica August MD and Jennifer J Huang DO

Department of Internal Medicine

University of Arizona

Tucson, AZ

References

1. Bae EJ, Hwang K, Jang HN, Kim MJ, Jeon DH, Kim HJ, Cho HS, Chang SH, Park DJ. A retrospective study of short- and long-term effects on renal function after acute renal infarction. Ren Fail. 2014;36(9):1385-9. [CrossRef] [PubMed]
2. Antopolsky M, Simanovsky N, Stalnikowicz R, Salameh S, Hiller N. Renal infarction in the ED: 10-year experience and review of the literature. Am J Emerg Med. 2012;30(7):1055-60. [CrossRef] [PubMed]
3. Tsai SH, Chu SJ, Chen SJ, Fan YM, Chang WC, Wu CP, Hsu CW. Acute renal infarction: a 10-year experience. Int J Clin Pract. 2007;61(1):62-7. [CrossRef] [PubMed]

Reference as: August J, Huang JJ. Medical image of the week: renal infarction. Southwest J Pulm Crit Care. 2015;10(4):195-6. doi: http://dx.doi.org/10.13175/swjpcc023-15 PDF

Medical Image of the Week: Hypertriglyceridemia-induced Pancreatitis

Figure 1. Panel A. Abdominal CT scan showing pancreatitis with edema and indistinct pancreatic borders (arrows). Panel B. Patient’s milky serum sample from elevated triglycerides. 

A 38 year old man presented with diffuse abdominal pain and was found to have pancreatitis on abdominal CT image (Figure 1, Panel A). His triglyceride level was 4573 mg/dL and his serum red top tube was visibly lipemic (Figure 1, Panel B).  He underwent one cycle of plasmapheresis and his triglyceride level decreased to below 500mg/dL.

Nathaniel Reyes, MD and Gordon Carr, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, AZ

Reference as: Reyes N, Carr G. Medical image of the week: hypertriglyceridemia-induced pancreatitis. Southwest J Pulm Crit Care 2013;6(1):22. PDF