An unusual cause of intestinal obstruction in an elderly woman: “The sign of the cane” in Morgagni hernia

Abstract

1016-3190/$ e see front matter Copyright 2012, Bu http://dx.doi.org/10.1016/j.tcmj.2012.06.001 A 79-year-old woman with hypertension was referred to our hospital because of intermittent periumbilical cramping pain lasting for one week. She had visited a local clinic, but her symptoms continued. Her abdominal distention progressed and she developed nausea and vomiting. In addition, she had no stool passage for 1 week. She had no history of abdominal surgery or abdominal trauma. Physical examination showed severe abdominal distention with diffuse tenderness. Hyperactive bowel sounds with ametallic gushing soundwere found over the right upper quadrant. Laboratory studies revealed leukocytosis (white blood cell count 12.1 109/L; normal: 3.8e9.8 109/L), hyponatremia (sodium: 131 mmol/L; normal: 136e145 mmol/L), and hypokalemia (potassium: 2.6 mmol/L; normal: 3.5e5.1 mmol/L). Preoperative chest radiography (Fig. 1A) and abdominal computed tomographic scan (Fig. 1B) were carried out. A radiological sign of Morgagni hernia (MH), the “sign of the cane“ was seen in the reformatted sagittal computed tomographic scan (Fig. 1C, arrows). A laparotomy was performed and a 2 cm diaphragmatic defect over the anteromedial aspect of the retrosternal region with one segment of incarcerated transverse colon and omentum was noted (Fig. 1D, arrows). The