Small bowel obstruction due to inguinal hernia

Case contributed by Yaïr Glick
Diagnosis certain


Lower abdominal and bilateral groin pain accompanied by vomiting since the day before admission to the ER. Passes small stools.

Patient Data

Age: 70 years
Gender: Male

Loops of small bowel dilated up to 4.2 cm in the central-left abdomen, with air-fluid levels.
Contents and gas in the ascending colon, gas in the rectum. The latter finding probably denotes an incomplete small bowel obstruction or a complete obstruction where the colonic contents have not yet been completely evacuated.
Prior cholecystectomy (known).
15 x 17 mm peripheral calcified nodule in the right upper abdomen, medial to the inferior rib - calcified lymph node? dropped gallstone?

  • many mildly dilated small bowel loops, some with air-fluid levels, some with a string of pearls sign
  • the transition point is a loop of ileum incarcerated in a large right inguinoscrotal hernia, showing a thickened, edematous wall and edema of its mesentery
  • the efferent bowel loop is collapsed right to the ileocecal valve
  • loop of sigmoid colon inside the same hernia, without signs of strangulation
  • copious amount of fluid inside the hernia
  • slightly hypoenhancing 9-mm lesion in hepatic segment 6, too small and hazy to characterize (due to movement artifact) 
  • the gallbladder has been removed
  • thick medial arm of left adrenal, no distinct lesion identified
  • peripherally calcified right renal artery aneurysm 14 mm in diameter
  • circumaortic left renal vein.
  • small mural thrombi on the posterior aortic wall at the level of the celiac trunk
  • bilateral moderate hydrocele

In summary:

  1. Small bowel obstruction, perhaps incomplete, due to ileal loop incarceration in large right inguinoscrotal hernia. The incarcerated loop shows signs of strangulation. Incarcerated loop of the sigmoid colon without such signs in the same hernia.
  2. Small calcified right renal artery aneurysm.


Case Discussion

The patient had had bilateral inguinal hernia repair many years previously.

Physical examination elicited tenderness in the right lower abdomen and the right groin. Huge rigid right scrotum. Impression of an inguinoscrotal hernia, signs of incarceration.
WBC 20K/uL with neutrophilia.
Abdominal x rays showed dilated small bowel loops with air-fluid levels.
CT abdomen showed that the etiology for small bowel obstruction was indeed the left inguinoscrotal hernia.

The hernia contents were explored: it contained a ~20 cm segment of small bowel with signs of strangulation but also a loop of the sigmoid colon. Due to an old mesh, the floor of the inguinal canal could not be restored, so a Prolene (polypropylene) mesh was laid down and fixed to the pubis, the conjoint tendon, and the ligament of Poupart while conserving the spermatic cord.

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.