Abdominal Lump in an Old Woman
Article Outline
An 89-year-old woman presented to our emergency department with persistent epigastralgia and vomiting for 2 days. She was afebrile and mildly tachycardiac (pulse rate 101 beats/min). Physical examination revealed a masslike lesion beneath the umbilicus (Figure 1). Blood tests showed leukocytosis (WBC count 21,600/μL; neutrophil 96%). Kidney ureter bladder abdominal radiograph revealed a small bowel gas collection with a large radiopacity in the lower abdomen.
Figure 1.
Physical examinations showed a masslike lesion palpated beneath the umbilicus.
Diagnosis
Spigelian hernia. Computed tomography (CT) of the abdomen demonstrated a ventral hernia containing peritoneal fat and segmental jejunum loops creating a small bowel ileus (Figure 2). At emergency laparotomy, an incarcerated hernia with omentum and 20 cm of ecchymotic small bowel without ischemic changes was found. A 4-×-4-cm2 fascial defect was repaired and she was discharged 3 weeks later.
Figure 2.
A round radiopacity was observed over the lower abdomen on radiograph (white arrows). The second image is the computed tomography of the abdomen.
Used with permission of Yu-Jang Su, MD, Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan.
Spigelian hernia, also known as spontaneous lateral ventral hernia, accounts for 0.12% to 2.4% of all abdominal wall hernias. They present most commonly in the fifth and sixth decades of life but can be observed at any age, with a female to male ratio of 1.4:1.1 The common symptoms are intermittent nonspecific pain and a bulging mass (up to 64% in one study).2 Small bowel obstruction is a rarely reported consequence.3 Incarceration at the operation is observed in 17% to 24% of reported hernias.1, 2 Image studies are recommended before surgical exploration. CT scan offers the detailed diagnosis and is generally recommended before surgery.
References
For the diagnosis and teaching points, see page 340.
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PII: S0196-0644(11)00096-5
doi:10.1016/j.annemergmed.2011.01.019
© 2011 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
