A Morgagni hernia is an uncommon diaphragmatic hernia. Complications such as obstruction
and resulting necrosis can be life-threatening, and surgery is mandatory. However,
minimally invasive treatments are preferred for elderly patients with comorbidities.
Although treatment of a Morgagni hernia by endoscopic reduction has been reported
[1], hyperinflation during colonoscopy may increase intraluminal pressure and exacerbate
incarceration. In the presence of an incarcerated Morgagni hernia, bowel preparation
for colonoscopy is impossible, and securing the visual field is difficult. Gel immersion
endoscopy has been reported to be useful for securing the visual field and decreasing
intraluminal pressure [2]
[3].
An 84-year-old woman with multiple cardiac comorbidities was hospitalized with epigastric
pain and vomiting. A computed tomography scan showed prolapse of the transverse colon
into the mediastinum and was consistent with obstruction due to a Morgagni hernia
([Fig. 1]). Bearing in mind the patient’s comorbidities, surgical treatment was considered
high risk. However, conservative treatment did not improve the obstruction. Colonoscopy
without bowel preparation was performed ([Video 1]). It was difficult to secure the visual field because of fecal impaction. However,
by injecting gel (Viscoclear; Otsuka Pharmaceutical Factory, Tokushima, Japan), a
transparent space between the tip of the endoscope and the intestinal wall was created
and maintained, enabling endoscope insertion without gas insufflation while keeping
the intraluminal pressure at a low level. A luminal constriction was found in the
transverse colon, thought to be at the orifice of the Morgagni hernia ([Fig. 2]). After insertion of the endoscope beyond the constriction, residual fluid and gas
in the dilated lumen were aspirated ([Fig. 3]). This reduced the herniation ([Fig. 4]) and enabled endoscope insertion to the ileocecal valve, confirmed by X-ray fluoroscopy
([Fig. 5]).
Fig. 1 A computed tomography scan showed prolapse of the transverse colon into the mediastinum
and was consistent with obstruction due to a Morgagni hernia. a axial view; b coronal view
Video 1 A Morgagni hernia treated by means of endoscopic reduction with low-pressure endoscopy
using the gel immersion method.
Fig. 2 A luminal constriction was found in the transverse colon, which was thought to be
at the orifice of the Morgagni hernia.
Fig. 3 After insertion of the endoscope beyond the constriction, fecal retention was observed.
Residual fluid and gas in the dilated lumen were aspirated, and the lumen collapsed.
Fig. 4 The collapsed lumen allowed endoscope insertion proximally, which reduced the herniation.
Fig. 5 The endoscope was inserted to the ileocecal valve, and hernia reduction was confirmed
by X-ray fluoroscopy.
Low-pressure endoscopy using the gel immersion method facilitates endoscopic reduction
as a minimally invasive treatment of a Morgagni hernia.
Endoscopy_UCTN_Code_CCL_1AD_2AJ
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