Small bowel obstruction due to Spigelian hernia

Case contributed by Dr Wayland Wang

Presentation

Vomiting

Patient Data

Age: 77
X-ray

Abdominal x-ray

Erect and supine views were performed. There are dilated loops of small bowel measuring up to 6 cm with multiple air fluid levels seen within them. Air is seen in the proximal colon but not distally. The findings are suggestive of a small bowel obstruction. Incidental note is made of a calcified gallbladder.

Volumetric CT abdomen and pelvis, with oral but not IV contrast (due to renal impairment).

There is dilatation small bowel up to 40 mm in diameter proximal to a transition point in the right iliac fossa, where a short segment of ileum enters a Spigelian hernia with a neck measuring 27 mm axially. The distal ileum and large bowel are collapsed. No peritoneal free gas or free fluid.

Geographic low attenuation in the liver adjacent to the porta hepatis is most likely focal fatty infiltration. Porcelain gallbladder noted. Two left adrenal gland nodules are stable. No gross abnormality of the pancreas, spleen, kidneys or right adrenal within the limits of the non-contrast technique. No intra-abdominal lymph node enlargement. A spiculated mass in the right lower lobe has significantly decreased in size since the previous CT, from 35 x 36 mm to 21 x 12 mm. Small nodules have developed in the right middle lobe and are likely infective in nature. Cardiomegaly is noted.

No suspicious bone lesions. Degenerative changes are noted in the lumbar spine.

Conclusion:
Ileal obstruction due to a Spigelian hernia in the right iliac fossa. Porcelian gallbladder. Significant decrease in size of the right lower lobe mass since the previous CT, presumably reflecting treatment. Small nodules in the right middle lobe, likely infective in nature.

Case Discussion

Hernias of various types are common causes for small bowel obstruction and are important to look for when assessing for a cause.
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Case information

rID: 50752
Case created: 20th Jan 2017
Last edited: 21st Jan 2017
Inclusion in quiz mode: Included

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