Madtown Sono

Elderly man with abdominal pain

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By Matthew Ka’ili, MD, MS
Edited by Hani I. Kuttab, MD and Leah Anderson, MD

Clinical Case

An elderly man with a past medical history of cirrhosis presented to the emergency department with three weeks of progressively worsening epigastric abdominal pain, nausea, and vomiting. The patient appeared uncomfortable. The examination was notable for a tense and tender periumbilical bulge, as well as a large fluid wave. A point-of-care ultrasound (POCUS) was performed.

Figure 1: Abdominal ultrasound (curvilinear probe) demonstrating a hernia sac with bowel contents, as well as dilated bowel more proximally.
Figure 2. Abdominal ultrasound over the suspected hernia site (linear probe) demonstrates bowel wall thickening and lack of peristalsis, which raises concerns for an incarcerated hernia.

Diagnosis

Incarcerated Umbilical Hernia with Small Bowel Obstruction (SBO). Abdominal ultrasound revealed a loop of small bowel within the hernia sac serving as a transition point for the resultant SBO. Imaging characteristics of SBO include small bowel dilation, wall edema, and a decompressed distal bowel. Additionally, this patient had a significant amount of ascitic fluid due to underlying liver disease, complicating bedside reduction. A CT scan of the abdomen and pelvis confirmed these findings. A nasogastric tube was placed, and general surgery was consulted. The patient was taken to the operating room for hernia reduction and repair.

Discussion

As discussed previously, POCUS can be a sensitive and specific tool for diagnosing SBOs. POCUS may also be utilized for the identification of various types of hernias. The benefit of POCUS is that it can be performed dynamically. For example, a patient may perform a Valsalva maneuver or stand during a POCUS examination to evaluate for possible hernia. POCUS may also be used in real-time to guide or confirm reduction of the hernia.

A hernia wall defect is usually found over the focal area of pain. Fat stranding may also be seen in this area, which appears as hyperechoic materials surrounding the bowel contents. Additionally, free fluid within the hernia sac may suggest possible incarceration or strangulation. Later findings include a thickened bowel wall and lack of peristalsis within the bowel contained within the hernia sac. Strangulated hernia may also demonstrate a lack of doppler color flow within the hernia.1

Several case reports have described the use of POCUS to also aid in the reduction of hernias.2-5 This is performed by identifying the hernia sac, applying gentle compression with the ultrasound probe and watching for hernia reduction in real time. Further studies are needed regarding the use of POCUS for diagnosing and reducing incarcerated hernias. The hope would be to reduce time from diagnosis to reduction (or surgical consultation if bedside reduction fails) and decrease the complication risk associated with prolonged incarceration.

Teaching Points

  1. POCUS is an efficient tool in diagnosing abdominal hernias, as well as complications such as small bowel obstruction and/or strangulation.
  2. POCUS can potentially play an important role in assisting with hernia reduction and/or in the confirmation of successful reduction, though more studies are needed.

References

  1. Jacomino K, Frasure SE, Boniface KS, Shokoohi H. Point-of-Care Ultrasound in the Diagnosis of an Incarcerated Inguinal Hernia. Cureus. 2021 Jul 9;13(7):e16281. doi: 10.7759/cureus.16281. PMID: 34377614; PMCID: PMC8349524.
  2. de Kok BM, Puylaert JBCM, Zijta FM. Ultrasound-guided reduction of an incarcerated obturator hernia in an elderly patient. J Clin Ultrasound. 2018;46(6):415-418. doi:10.1002/jcu.22562.
  3. Baik J, Lee Y. Reduction En-masse of Inguinal Hernia with Incarcerated Bowel: Report of a Rare Case. Am J Case Rep. 2019;20:1562-1565. doi:10.12659/AJCR.918059.
  4. Torzilli G, Del Fabbro D, Felisi R, et al. Ultrasound-guided reduction of an incarcerated Spigelian hernia. Ultrasound Med Biol. 2001;27(8):1133-1135. doi:10.1016/s0301-5629(01)00402-1.
  5. Siadecki SD, Frasure SE, Saul T, Lewiss RE. Diagnosis and reduction of a hernia by bedside ultrasound: a case report. J Emerg Med. 2014;47(2):169-171. doi:10.1016/j.jemermed.2013.09.026.