What Is Your Diagnosis?

Received: March 8, 2004

Respiration 2005;72:301303
Accepted after revision: April 28, 2004
DOI: 10.1159/000085375

A Mass in the Right Cardiophrenic Angle

Steven J. Michel a Eric S. Bensadoun b
a Department of Diagnostic Radiology and b Division of Pulmonary and Critical Care Medicine, University of

Kentucky, Lexington, Ky., USA

A 38-year-old male was seen in consultation for an
abnormal chest radiograph. His only complaint had been
tingling in his hands and some vague right-sided lower
chest discomfort. He denied cough, shortness of breath,
hemoptysis, weight loss or history of trauma. He was
physically active and had no other medical problems. He
had recently quit smoking, but had smoked 1 pack per
day for 10 years. As part of his evaluation he had a chest
x-ray, which was abnormal and prompted the consulta-
tion.
On examination his vital signs were normal and the
remainder of the physical exam was unremarkable. Labo-
ratory tests including a CBC and chemistry panel were
normal. His chest x-ray (fig. 1) showed a large mass in the
area of the right cardiophrenic angle. A CT scan of the
chest was performed (fig. 2).
What is your diagnosis?

Fig. 1. Posteroanterior and lateral chest radiograph demonstrating a right cardiophrenic Fig. 2. CT of the chest demonstrates a large
angle mass, which is located in the anterior part of the right hemithorax. mass adjacent to the right heart border. The
density of the mass is consistent with fat.

2005 S. Karger AG, Basel Eric S. Bensadoun, MD, FCCP

ABC 00257931/05/07230301$22.00/0 University of Kentucky, Division of Pulmonary and Critical Care Medicine
Fax + 41 61 306 12 34 740 South Limestone, K528 Kentucky Clinic
E-Mail karger@karger.ch Accessible online at: Lexington, KY 40536-0284 (USA)
www.karger.com www.karger.com/res Tel. +1 859 323 5045, Fax +1 859 257 2418, E-Mail ebens0@email.uky.edu
 Diagnosis: Diaphragmatic Hernia through the Foramen of Morgagni

Coronal and sagittal reformatting of the CT images
confirmed the presence of an anterior diaphragmatic
defect in the area of the foramen of Morgagni with omen-
tum herniating into the right hemithorax (see fig. 3).
Diaphragmatic hernias can be grouped into the follow-
ing categories: congenital diaphragmatic hernias, hernias
that result from blunt or penetrating trauma to the dia-
phragm, and hiatal hernias. Congenital diaphragmatic
hernias can occur through several embryologic defects in
the diaphragm, including the posterolateral foramen of
Bochdalek, and the anterior midline foramen of Morgagni
[1].
First described by Giovanni Morgagni in 1761, the
Morgagni hernia is the least common of the diaphragmat-
ic hernias comprising only 23% of all surgically treated
hernias [1]. The Morgagni hernia is the result of a defect
in the septum transversum, which is due to the failure of
fusion of sternal and costal components of the diaphragm
during embryonic development [2, 3]. This anatomic
defect, known as the foramen of Morgagni, is usually
located immediately posterior and to the right of the ster-
num. Morgagni hernias are typically right-sided (90%),
but left-sided (2%), and bilateral (8%) ones have been
described [3]. The hernia always has a peritoneal sac, and

Fig. 3. Reformatted CT images. The sagittal

view (A) and coronal view (B) demonstrate
the defect in the diaphragm (arrows). These
images confirm the parasternal location of
the diaphragmatic defect and demonstrate
the continuity between the omental fat and
the fat density comprising the right paracar-
diac mass. The fine linear densities running
through the diaphragmatic defect are omen-
tal blood vessels.

302 Respiration 2005;72:301303 Michel/Bensadoun

most commonly contains only omentum, although colon,
stomach, small intestine, and liver can also be found in
the hernial sac [3, 4].
Morgagni hernias are more common in women, often
diagnosed in adulthood, and unlike other types of dia-
phragmatic hernias, Morgagni hernias are only rarely
associated with other congenital anomalies [2, 3]. Patients
are generally asymptomatic and are often diagnosed as a
result of an incidental finding on a chest radiograph.
Symptoms are nonspecific and include abdominal pain,
chest discomfort, and dyspnea. In some cases these symp-
toms have been ascribed to compression of lung by an
enlarging hernia, intermittent gastric volvulus, and to gas-
trointestinal tract obstruction or incarceration [46].
On chest radiograph Morgagni hernias usually consist
of a homogeneous opacity in the right cardiophrenic
angle. The lateral chest radiograph confirms the anterior
position of the opacity, and although uncommon, an air
fluid level in this location is thought to be pathognomonic
of a Morgagni hernia. The differential diagnosis of a car-
diophrenic angle mass includes epicardial fat pad, peri-
cardial cyst, lipoma, and Morgagni hernia. CT imaging
can be very helpful in differentiating these various etiolo-
gies. The presence of a mass of fluid density suggests a
pericardial cyst while a lesion of fat density can be consis-
tent with a fat pad, lipoma or a Morgagni hernia contain-
ing omental fat. Linear densities within the fat, repre-
senting omental vessels, favor the diagnosis of a Morgagni
hernia rather than a lipoma or fat pad [3, 7]. If the mass is
heterogeneous or contains soft tissue density then terato-
ma, liposarcoma, or a thymolipoma must be considered.
Sagittal and coronal reformatted CT images can be help-
ful in demonstrating the diaphragmatic defect, identi-
fying the contents of the hernia, and aiding in preopera-
tive planning [8]. MR imaging with its multiplanar views
offers similar advantages in identifying the hernia defect,
and can also confirm the fatty nature of the hernia [9].
The use of barium enema, upper gastrointestinal series or
liver scan to confirm the presence of hernia and demon-
strate the contents of the hernia sac has largely been sup-
planted by CT and MR and is primarily of historical inter-
est.
In adults surgical repair of Morgagni hernias is usually
only indicated when symptoms are present although some
authors recommend surgical repair even in asymptomatic
patients because of the risk of strangulation [3, 4, 10].
Open surgical repair via an abdominal, or transthoracic
approach has traditionally been performed. Regardless of
the approach, the goals of the operation are the same:
reduction of the contents of the hernia, excision of the
hernia sac and closure of the diaphragmatic defect to pre-
vent recurrences [2, 7]. Recent advances in minimally
invasive surgery have led to reports of closure of foramen
of Morgagni hernias using laparoscopic and thoracoscopic
techniques, and a possible decreased morbidity when
compared with open surgical procedures [2, 1013].
Key Words
Congenital W Diaphragm W Hernia W Morgagni W
Pericardiac mass

References

1 Hartman GE: Diaphragmatic hernia; in Behr-
man RE, Kliegman RM, Arvin AM (eds): Nel-
son Textbook of Pediatrics, ed 15. Philadel-
phia, Saunders, 1996, pp 11611164.
2 Naunheim KS: Adult presentations of unusual
diaphragmatic hernias. Chest Surg Clin N Am
1998;8:359369.
3 Hinshaw LJ, Collins J: Case of the season:
Foramen of Morgagni hernia. Semin Roent-
genol 2002;31:34.
4 LaRosa DV, Esham RH, Morgan SL, Wing
SW: Diaphragmatic hernia of Morgagni. S Med
J 1999;92:409411.
5 Basin DK, Nagi B, Gupta NM, Singh K:
Chronic intermittent gastric volvulus within
the foramen of Morgagni. Am J Gastroenterol
1989;89:11061108.
6 Wong NA, Dayan CM, Virjee J, Heaton KW:
Acute respiratory distress secondary to Mor-
gagni diaphragmatic herniation in an adult.
Postgrad Med J 1995;71:3941.
7 Gerard PS, Wilck E, Senderoff E, et al: Morga-
gni hernia mimicking a lipomatous tumor. N Y
State J Med 1993;93:5859.
8 Gilkeson RC, Basile V, Sands MJ, Hsu JT:
Chest case of the day. AJR Am J Roentgenol
1997;169:266274.
9 Yeager BA, Gugliemi GE, Schrebler ML, Gef-
ter WB, Kressel HY: Magnetic resonance imag-
ing of Morgagni hernia. Gastrointest Radiol
1987;12:296298.
10 Ipek T, Ediz A, Serdar Y, et al: Laparoscopic
repair of a Morgagni-Larrey hernia: Report of
three cases. Surg Today 2002;32:902905.
11 Huntington TR: Laparoscopic transabdominal
preperitoneal repair of a Morgagni hernia. J
Laparoendosc Surg 1996;6:131133.
12 Hussong RL, Landreneau RJ, Cole FH: Diag-
nosis and repair of a Morgagni hernia with vid-
eo-assisted thoracic surgery. Ann Thorac Surg
1997;63:14741475.
13 Rau HG, Schardey HM, Lange V: Laparoscop-
ic repair of a Morgagni repair. Surg Endosc
1994;8:14391442.

A Mass in the Right Cardiophrenic Angle Respiration 2005;72:301303 303