An unusual hernia in an elderly

19 May

Introduction

The evaluation of elderly with intra abdominal pathology on the emergency department (ED) is a challenging one, since they tend to have a very vague presentation. It is not unusual that the abdominal complains are fully at the background. The difficult evaluation and the high mortality rate makes this a very high risk group on the ED. For this reason it is very important for ED doctor to know the differential diagnosis and how to differentiate between them.

Case Report

A 83 year old woman with parkinson’s disease was referred at night by her family doctor with dyspnoea and elevated temperature.

 

She was believed to have a urosepsis. No abdominal pain was noted.
On presentation on the ED she clearly was short of breath, weak and she had an altered mental state. According to her son she was in fairly good condition the day before.
Her vital sings showed a heart rate of 120 beats/minute, respiratory rate of 30 breath/min, blood pressure of 90/60 mmHg and rectal temperature of 38.6°C. Her pulse oximetry was 95% with 5L oxygen via an oxygen mask.

On physical exam she had a bulby, tender, hypertympanic, painful abdomen, without bowel sounds. On the outside was no herniation palpable.
The laboratory data obtained at admission showed low leucocytes with elevation of the CRP, lactate, lactate dehydrogenases, pancreas amylase and kidney functions. The arterial blood gas showed an respiratory fully compensated metabolic acidosis and there were leucocytes in the urine.
Since she was clearly in shock extensive infusion and antibiotics were started. The chest X-ray showed no new pathology, after which a CT of the abdomen was performed. This showed a very strongly dilated stomach with dilation of the small bowels filled with fluid, without free air. In the right lower abdomen a part of the small bowel was strangulated between the m. pectineus (1 in picture) and the m. obturatorius externus (2 in picture).  Patient got an gavage and a operation was performed that same night under the diagnosis “incarcerated obturator hernia”.
During the operation a hernia sac was seen through the fossa obturatorium. This sac was mobilized and the herniation was reduced with loose sutures.
Postoperative the patient shortly went to the Intensive Care, but the postoperative process was without complications.
Currently she has left the hospital in good health.

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