Simultaneous occurrence of subcostosternal (Morgagni) hernia and hiatus hernia; report of a case.

Abstract

The simultaneous occurrence of two separate nontraumatic diaphragmatic hernias is extremely rare. In 1941 Harrington (1) reported the first case of herniation of omentum through the foramen of Morgagni occurring simultaneously with hiatus hernia. In a review of the literature in 1951, Saltzstein, Linkner, and Scheinberg (2) were able to find 10 cases of bilateral subcostosternal (foramen of Morgagni) hernia. As a single defect, diaphragmatic hernia is not unusual, particularly in persons over fifty years of age. The most common form is hiatus hernia, which comprises 70 per cent of all diaphragmatic hernias (3). Brick and Amory (4) found hiatus hernia in 1.3 per cent of 300 asymptomatic persons over the age of fifty, with an even higher incidence in symptomatic patients. Portis and King (5) reported an incidence of 7.5 per cent in a series of 133 patients over sixty. Hernia through the foramen of Morgagni, on the other hand, is the rarest of diaphragmatic hernias, comprising only 2.6 per cent of such defects (2). In 430 cases of operated diaphragmatic hernia, Harrington (6) found only 8 to be subcostosternal. Herniations through the esophageal hiatus and the foramen of Morgagni have several features in common. Both types are rare at birth, occurring usually in later life, most often after the age of fifty. Both are seen more commonly among women (2, 7). They are the only types of diaphragmatic hernia with true hernial sacs, suggesting that they develop after complete closure of the diaphragm. In an excellent discussion of the subject Harrington (8) suggests that imperfect embryological development plays an important role in the etiology of these hernias, in spite of the delay in their appearance. Bizarre symptoms are often encountered in both hiatus hernia and subcostosternal hernia. Frequently these hernias are confused radiographically with pleural cyst, pulmonary cyst, pericardial cyst, hydatid cyst, empyema, mediastinal tumor, intrathoracic tumor, or other intrathoracic conditions, including various forms of cardiac disease (3, 9). If the hernia contains hollow viscera of the gastrointestinal tract, the diagnosis is usually readily made by barium contrast studies. When these fail to reveal the nature of the abnormality, pneumoperitoneum may be used (10). Such a procedure may outline the hernial sac and demonstrate its extrapleural character. The following case is presented as the second reported example of simultaneous occurrence of hiatus hernia and subcostosternal hernia. It is, as far as we can determine, the only reported case in which both defects contained hollow viscera, permitting the diagnosis to be made by barium contrast studies. Case Report A 62-year-old white female sought medical attention in August 1957 because of a five-year history of intermittent, postprandial, substernal pain, radiating on occasion to the left shoulder and frequently accompanied by moderate dyspnea.