An Unusual Cause of Profound Weight Loss in a Middle-aged Person

First described in 1761 by Giovanni Morgagni, 1682–1771, Professor of Anatomy, Padua, Italy,¹ hernia through the foramen of Morgagni is an anteriorly manifesting hernia arising from a defect between the septum transversum and the costal attachments of the diaphragm. It is the rarest form of diaphragmatic hernia, accounting for less than 1% of surgically treated diaphragmatic hernias. Transverse colon is the most common herniating viscus, with the herniation of the stomach much less common.² The pathophysiology is dependent on the herniating viscus, and the clinical presentation is contingent on the presence or absence of viscus obstruction or ischemia.^1,3 We describe a case of acute profound weight loss due to herniation of the stomach through the foramen of Morgagni and a review of the literature.

Case Report

A 41-year-old Hispanic man was referred for gastroenterologic evaluation after 3 weeks of postprandial epigastric pain with nonprojectile emesis. The pain occurred approximately 5 minutes after ingesting food and was dull in character, nonradiating, and relieved by vomiting. His primary care physician had treated his pain with proton pump inhibitors, with no symptom improvement. His bowel motion was unchanged at 4 times per week, and there was no progressive increase in abdominal girth or dyspnea. He had lost 34 pounds since the onset of his complaint.

The patient had no history of coronary or peripheral atherosclerosis, connective tissue disorder, or chronic remittent epigastric pain. He had not undergone any surgical procedure, and there were no symptoms of hyperthyroidism. HIV antibody and purified protein derivative of tuberculosis examinations were negative, and computed tomography (CT) of the abdomen showed no abnormality.

Physical examination revealed a 5′6″, 120-pound asthenic male in no distress. His blood pressure was 110/60 mm Hg; his pulse was 78 bpm regular, and respiratory rate was 20/min. Conjunctiva was pink, sclera was anicteric, there was no adenopathy, and oral mucosa was moist with good skin turgor. His abdomen was scaphoid with no surgical scars, no visible peristaltic wave, no succussion splash, no bruit, no palpable mass, and bowel sounds were normal. Digital examination revealed normal-colored form stool.

Esophagogastroduodenoscopy showed an hourglass distortion of the stomach due to a midgastric corpus extrinsic compression with occlusion of more than 95% of the gastric lumen and gastric folds converging to the point of constriction; no mass or mucosal ulceration was noted. Upper gastrointestinal (UGI) series for further delineation of the anatomy showed midgastric obstruction with gastroesophageal reflux (Figure 1).

Figure 1.

Upper gastrointestinal series: barium retained in proximal stomach with reflux due to midgastric obstruction.

The patient underwent exploratory laparotomy; a diaphragmatic hernia of Morgagni containing the stomach, which was constricted in the middle, was found, as well as a loop of the transverse colon. The hernia contents were not spontaneously reducible due to fibrosis and scarring at the base of the hernia. Adhesions were lysed and the hernia contents reduced into the abdominal cavity, with repair by suturing of the foramen of Morgagni. There was no associated paraesophageal hernia. The patient recovered with complete resolution of his postprandial pain and emesis and has gained 6 pounds since surgery.

Discussion

This case demonstrates the clinical course of a patient with incomplete gastric obstruction due to herniation through the foramen of Morgagni. Typically, postprandial epigastric pain with significant weight loss is due to chronic mesenteric ischemia, gastric ulcer, or gastric malignancy.¹ Herniation of the stomach through the foramen of Morgagni is uncommon² and is not a well-characterized cause of this clinical presentation. There have been less than 10 cases of gastric herniation described in the literature.^2,4,5 Herniation of the stomach presents with symptoms suggestive of gastric volvulus and gastric outlet obstruction.^2,5 However, our review indicates that this is the first instance of acute profound weight loss in a middle-aged person as the key feature of presentation, although this may be due to lack of reporting.

Ninety percent of hernia cases of the foramen of Morgagni occur on the right side of the diaphragm, as the left side of the diaphragm is enhanced by the heart and pericardium. In adults, the pathology is seen more in women and individuals over age 50. Transverse colon is the most common viscus herniating through the foramen. Other intra-abdominal structures described as herniating through the foramen include the greater omentum and the liver.^3,6–10 Abdominal symptoms predominate in obese patients and nonobese patients tend to have respiratory symptoms. The diagnosis of hernia of the foramen of Morgagni is usually suspected on thoraco-abdominal CT, which shows an intra-abdominal viscus with oral contrast in the anterior chest, usually in the right thorax.^4,6–8 Esophagogastroduodenoscopy is usually not helpful in diagnosis.

Once diagnosis is confirmed, surgical correction is mandatory. Laparoscopic or open transabdominal or transthoracic repair have been described. Excision of the hernia sac is optional; leaving it behind is believed to reduce pleural and pericardial injury and prevent escape of carbon dioxide into the thorax.^2,3,7,9 Direct interrupted or running suture repair can be used for small defects. Suturing with mesh prosthesis is the method of repair for large diaphragmatic defects.

Conclusion

Hernia of the foramen of Morgagni should be considered in the differential diagnosis of a middle-aged patient with no risk factor for chronic mesenteric ischemia or acid peptic disorder, who presents with profound weight loss and UGI obstructive symptoms.