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.
No radiographic evidence of pneumoperitoneum (Rigler's sign).
Numerous amount of air pockets scattered over the large area of left sided abdomen and pelvis, suspicious of subcutaneous gas.
Presence of lower midline incisional laparotomy scar from the previous total abdominal hysterectomy surgery.
Wide neck of incisional hernia with small bowel loops within the hernia sac.
"Double beak sign" noted at the hernia neck where two sites of tapering bowel loops indicate the point of obstruction. The small bowel loops distant to the hernia neck (point of obstruction) is not dilated as there is air-filled tract in keeping with perforated site. A large collection located adjacent to this perforated site within the hernia sac.
Proximal small bowel loops prior to entry into the incisional hernia are grossly dilated. No intramural gas, portal venous gas or pneumoperitoneum.
Bowel wall and mucosa enhancement preserved.
Significant amount of subcutaneous gas over the lower abdomen, predominantly at the left side.
Fat streakiness and abdominal skin thickening denote the on-going inflammatory/infective process.
Large colon and distal ileum are collapsed.
Photo showed the physical examination of the patient's distended abdomen, where generalized 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 necrotizing 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. Fecal 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)
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