Pantaloon hernia

Case contributed by Dr Craig Hacking

Presentation

Incidental finding

Patient Data

Age: 70 years
Gender: Male
CT

The lower pole moiety of the duplex left kidney demonstrates severe hydronephrosis with dilatation up to 20.5 cm, marginally increased from 19.5 cm on the previous study. The distended renal pelvis demonstrates a density of 10 HU, with no significant enhancement on arterial or delayed phases.

The left renal cortex is markedly thinned. The distal left ureter is not dilated.

At the anteroinferior margin of the distended pelvis is a bulge measuring 4.7 x 2.5 cm with a density of 4 HU, unchanged in appearance. Medial to this is a soft tissue density (30 HU) mass measuring 5.7 x 3.4 cm which has increased in size from 3.2 x 1.4 cm. This has an enhancing, thickened wall and exerts mass affect on the adjacent renal pelvis.

There is adjacent inflammatory stranding. The dilated left lower pole renal pelvis crosses the midline and the pelvic brim and exerts significant mass effect on adjacent structures including the left renal arteries and upper pole moiety and its proximal ureter which demonstrate moderate hydronephrosis and hydroureter (up to 1.7 cm).

The right kidney is normal. The right ureter opacifies normally with contrast to the vesicoureter  junction. The bladder fills with contrast. Subtle irregularity of the anterior wall of the bladder is difficult to assess given that it is not distended.

The partially imaged liver demonstrates subcapsular hypodensities in segments V and IVb adjacent to ligamentum teres.

Surgical clips in the gallbladder fossa are in keeping with cholecystectomy.

The sigmoid colon demonstrates diverticular disease. Direct (containing fat) and indirect (containing small bowel) right inguinal hernia (pantaloon hernia). Indirect left inguinal hernia containing fat.

No free intra-abdominal fluid or gas detected.

Para-aortic lymph nodes are prominent, the largest measuring 15 x 9 mm.

The imaged lung bases reveal dependent changes and scarring/atelectasis in the posterobasal segment of the left lower lobe. The spine demonstrates degenerative change.

No suspicious bony lesion detected.

Conclusion

  • Marked dilatation of the lower pole moiety of the duplex left kidney has progressed slightly since the prior CT.
  • Soft tissue mass at the anteroinferior margin of the dilated renal pelvis, also increased in size, is highly suspicious for malignancy complicated by obstruction. Review of preview of previous suggests that this could be metastatic sarcoma or TCC.
  • Hepatic subcapsular hypodensities are consistent with focal fatty infiltration (see previous CT).
  • Incidental right inguinal pantaloon hernia.

Case Discussion

Example of a pantaloon hernia: an inguinal hernia with both direct and indirect components.

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Case information

rID: 38673
Case created: 29th Jul 2015
Last edited: 14th Sep 2017
Inclusion in quiz mode: Included

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