Presentation
Abdominal distension with one-week history of abdominal pain and fever.
Patient Data
Multiple loops of dilated small bowel, as evidenced by presence of valvulae conniventes.
Presence of lower midline incisional laparotomy scar from the previous total abdominal hysterectomy surgery.
Photo showed the physical examination of the patient's distended abdomen, where generalised erythema of the skin/cellulitis.
Annotated images for showing the transition point, perforation site, herniated small bowel loops and abscess formation.
Case Discussion
Overall urgent CT abdomen and pelvis showed the complication of incarcerated hernia where the herniated small bowel loops through the incision became perforated due to closed loop obstruction resulting in abscess formation and cellulitis. The presence of large degree of subcutaneous gas raise suspicion of necrotising fasciitis.
Emergency laparotomy of small bowel resection, primary anastomosis and wound debridement performed.
Intraoperative findings: 10x10cm hernia defect, content was big clump of distal ileum with multiple sites of perforation, 150cm from duodenal jejunal junction, 50cm from terminal ileum. Faecal contamination extraperitoneally and unhealthy anterior abdominal wall.
**Case and image courtesy of Dr Noorakmal Abdullah and Dr Mohd Shafiq (Radiology Department, Hospital Ampang, Selangor, Malaysia)