An unusual hernia in an elderly

19 May

Discussion

The obturator hernia is a herniation of abdominal contents in the obturator foramen. It is very rare (0,6% of all abdominal herniations) with high mortality (10-50%)1,2,3 It is the cause in about 0,5% of all obstruction ileuses.
At the craniolateral side of the obturator foramen is the obturator canal located, through which the a., v. and n. obturatorius run. Compression of the obturator nerve by the hernia sac produces the pathognomonic Howship-Romberg sign. It involves pain along the medial aspect of the thigh to the knee and, less often, the hip. This referred pain is relieved by flexion of the thigh and exacerbated by abduction, extension, and medial rotation. Although this sign of Howship-Romberg is pathognomonic, it is only present in 15-50% of the patients.4,5 Often there is also a motor failure of the adductors, that will lead to failure of adduction and flexion of the leg. Because the sensible phenomena dominate, this motor phenomena can easily be missed.
The adductor reflex test is more sensitive, but more unknown. During this test the doctor hits with a reflexhammer on his own finger, which is located 5 cm above medial femurepicondyl on the adductors. A isolated failure of this adductor reflex, whereby the adductor reflex on the contra lateral and the patellar reflex on the ipsilateral side are present is termed the Hannington-Kiff sign. 2,4
Sometimes a mass is palpable on rectal and vaginal exam. On the outside hardly ever a herniation is palpable.
The obturator hernia is mostly seen in eldery, thin, multipara women and more often on the right side.3,6 Most patients complain of abdominal pain with nausea. A lot of patient also have pain in the thigh and mention previous episodes of similar complaints.
CT is the diagnostic tool of choice.3,5,7,8,9

Since the evaluation of elderly with intra abdominal pathology on the ED is very difficult and the mortality is very high (5% after 2 weeks of follow-up)10, it is important to come to the right diagnosis fast. Herefore an ED doctor needs to know the broad differential diagnosis (tabel 1) and how to differentiate between them. A good anamnesis and physical exam is hereby of vital importance (tabel 2).
During a good physical exam either the Howship-Romberg sign or the Hannington-Kiff sing can be examined. These sings are very often overlooked, especially since the use of CT. Missing these sign might lead to a delay in diagnosis and to delay in treatment, but very often other clinical sign will put you in the right direction.

References:
1.)Satorras-Fioretti AM, Vázquez-Cancelo J, Pigni-Benzo L, Salem AM, Ramos-Ardá A. Hernais de pared abdominal de localización poco frecuente. CIRĢIA ESPAŇOLA. 2006; 79(3): 180-183.
2.) Brosterhaus D, van Oyen JA. Obstruction ileus with leg pain: think of an obturator hernia
Ned Tijdschr Geneeskd. 1993; 137(43): 2177-9.
3.) Kammori M, Mafune K-I, Hirashima T, Kawahara M, Hashimoto M, Ogawa T, et al. Forty-three cases of obturator hernia. Am J Surg. 2004; 187(4): 549-52.
4.) Nakayama T, Kobayashi S, Shiraishi K, Nishiumi T, Mori S, Isobe K, et al. Diagnosis and treatment of obturator hernia. Keio J Med. 2002; 51(3): 129-32.
5.) Wang GY, Qian H-r, Cia X-y, Fang S-h, Shen L-g . Strangulated obturator hernia diagnosed preoperatively by spiral CT: case report. Chin Med J (Engl). 2007; 120(20): 1855-6.
6.) Thanapaisan C, Thanapaisal C. Sixty-one cases of obturator hernia in Chiangrai Regional Hospital: retrospective study. J Med Assoc Thai. 2006; 89(12): 2081-5.
7.) Ijiri R, Kanamaru H, Yokoyama H, Shirakawa M, Hashimoto H, Yoshino G. Obturator hernia: the usefulness of computed tomography in diagnosis. Surgery. 1996; 119(2): 137-40.
8.) Bergstein JM, Condor RE. Obturator hernia: current diagnosis and treatment.
Surgery. 1996; 119(2): 133-6.
9.) Greenberg G, Shapiro-Feinberg M, Zissin R. Small bowel obstruction due to obturator hernia: CT appearance. Isr Med Assoc J. 2002 May;4(5):391-2.
10) Lewis LM, Banet GA, Blanda M, et al. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. J Gerontol A Biol Sci Med Sci. Aug 2005;60(8):1071-6

Intra abdominal pathology in Elderly

Diseases of gallbladder or bile ducts, Appendicitis, Diverticulitis, Pancreatitis, Mesenterial Ischemia, AAA, Peptic Ulcera, Malignancy, Gastro-enteritis, Obstipation, Urinary Tract Infection, Kidney stones/ Urinary-retention, PID, Spontaneous bacterial sepsis
Darmobstruction:
Small bowel: postsurgical adhesions, malignancy, hernia, IBS, volvolus
Large bowel: malignancy, diverticulitis, volvolus, myocardial infarction, Pneumonia, Diabetic Ketoacidosis, Herpes Zoster

Extra abdominal pathology in Elderly that can present as abdominal pain

Myocardial infarction, Pneumonia, Diabetic Ketoacidosis, Herpes Zoster

Egon

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