Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

Bowel in the pericardium: Spontaneous herniation mimicking acute aortic dissection?

Abstract

Intra-pericardial herniation of abdominal contents is rarely encoun- tered in emergency practice. The entity is most often the result of blunt or penetrating trauma and also may occur post-operatively. Spontane- ous herniation through a Morgagni hernia is even rarer but presents the opportunity for lifesaving diagnosis and treatment. We present the case of an octogenarian presenting with the acute onset of symptoms suggestive of aortic dissection. She was found to have herniated trans- verse colon within the pericardial sac concerning for strangulated bowel. Timely surgical intervention led to a favorable outcome. Emer- gency clinicians should be aware of this life-threatening but eminently treatable entity.

The patient was an 86-year-old woman who presented to our emer- gency department with a sudden onset of Epigastric pain radiating to the back of 2 hours’ duration. The pain was accompanied by diaphoresis and a near syncopal episode as well as several bouts of non-bilious, non-bloody emesis. She denied chest pain, shortness of breath, fever, chills, and cough. The patient acknowledged chronic constipation that was worse over last few days, but denied other Gastrointestinal symptoms or similar prior episodes. The past history was positive for coronary artery disease, prior myocardial infarction, hypertension, high cholesterol, and atrial fibrillation status post ablation on rivaroxaban. Patient had no histo- ry of trauma or previous surgical operation. The electrocardiogram was notable only for sinus rhythm of 82 with non-specific ST and T-wave ab- normalities. Laboratory investigation revealed a white count of 18 400; there was no left shift. The initial lactate was 1.6, troponin was 0.02, and the remainder of the Laboratory analysis was unremarkable.

The physical exam was notable for Elderly woman in marked dis- tress, with epigastric pain and tenderness partially relieved by 4 mg of Intravenous morphine. The initial vital signs were a blood pressure of 178/98, heart rate of 95, respiratory rate 17, oxygen saturation of 96% on room air; she was afebrile. Shortly after initial stabilization the pain again increased and repeat bedside blood pressure was noted to be 74/46. A computed tomographic (CT) scan to rule out aortic dissection was promptly performed. This scan revealed no evidence of dissection, but was positive for “several loops of bowel contained with the pericar- dial sac…consistent with a Morgagni Hernia.” (Figure A and B) The in- terpretation noted that a previous CT scan performed 10 months earlier, was also positive for bowel loops within the pericardial sac but noted that the appearance of those loops had changed, suggestive of strangulation without evidence of obstruction.

She was admitted to the surgical intensive care unit where subse-

quent CT studies confirmed the presence of a bowel herniation through

? There are no conflicts of interests. The MS has not been submitted elsewhere.

a Morgagni hernia without radiographic evidence of obstruction. Naso- gastric suction was applied with apparent amelioration of symptoms. Laparoscopic visualization on the third hospital day confirmed the pres- ence of anterior diaphragmatic hernia of a Morgagni type with trans- verse colon noted in the pericardium. The bowel was retracted from the pericardium and the diaphragmatic hernia was closed with surgical mesh. Patient tolerated the procedure well and was discharged on the third postoperative day.

Intra-pericardial herniation of abdominal contents is a Rare condition which is almost exclusively limited to congenital defects in the newborn or as a result of blunt or penetrating trauma [1]. Our case represents the extremely Rare occurrence of bowel passing through a Morgagni defect into the pericardium without history of trauma. What appears even more remarkable is that this presented as an acute emergency in the 9th decade of life.

The rarity of intra-pericardial herniation is reflected by the predom- inance of case reports regarding this entity, mostly in the surgical liter- ature [2,3,4]. Reviews of Morgagni hernia, usually with herniation into the thoracic cavity have noted that approximately half of all cases are asymptomatic when discovered on plain film and confirmed on CT [5,6]. The average age at diagnosis in a recent series was noted to be 45; Males and females are affected equally [7]. It is unclear in the rare cases such as ours, when or how the hernia developed; in our case the bowel herniation was noted 10 months previously, but absent on CT scan obtain 9 years previously. The patient and family denied any trau- ma in this interval.

Morgagni first described intrathoracic herniation of abdominal con- tents on autopsy in 1769. The diaphragmatic defect that now bears his name is a triangular space form by the muscle fibers of the diaphragm that originates from the xiphoid and costal margin and inserts on the central tendon of the diaphragm. Presumably an increase in intraabdominal pressure as with pregnancy, obesity and trauma leads to either gradual or acute herniation of the bowel or stomach into the thoracic cavity and, very rarely, into the pericardium. A similar dia- phragmatic weakness but more posterior and to the left of the Morgagni defect, is responsible for the entity known as the Bochdalek hernia.

Treatment of intrathoracic and intra-pericardium herniation has evolved in recent decades. Older reviews emphasized repair through open thoracotomy. More recent approaches emphasized abdominal laparoscopic visualization, reduction and repair. The morbidity using this approach is minimal and postoperative hospital stay approximates 3 days as in our case [6].

The spontaneous presentation of our geriatric patient with severe pain mimicking aortic dissection highlights the importance for emer- gency clinicians to consider this diagnosis. It may well be suspected on routine chest x-ray and is easily confirmed by CT scan. If complicated

0735-6757/(C) 2016

Figure. CT demonstrates Morgagni hernia with bowel passing through into the pericardium. White solid arrows indicate the loops of bowel in the pericardium. A, Coronal image. B, Axial image.

by strangulation, obstruction, or perforation it represents a life threaten- ing condition that is amendable to laparoscopic Surgical repair.

Daniel S. Frank, MD Michael Heller, MD^? Jennifer Sedor, MD Namita Kedia, MD Adina Shulman, RN Elias E. Wan, MD

Department of Emergency Medicine,

Mount Sinai Beth Israel, Icahn School of Medicine, New York, NY 10003

^?Corresponding author.

http://dx.doi.org/10.1016/j.ajem.2016.03.012

References

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