br Conclusions br Introduction Inguinal hernias are very com
Introduction Inguinal hernias are very common in elderly male adults, but blunt contusion to the hernia causing intestinal perforation is rare. The computed tomographic (CT) scan has become an important diagnostic tool in evaluating abdominal injuries; however, physicians can over depend on modern technology for diagnosis without noting the essential limitations in that scans cannot provide information of real-time changes of a patient’s status. Therefore, it is essential to combine continuous clinical evaluations and modern technology to make a correct diagnosis. We present here a patient with ileal perforation after blunt abdominal injury. The first CT scans did not show any specific findings above a left inguinal hernia. However, the intermittent but persistent abdominal pain with obscure peritoneal signs and hypotension, initiated serial work-up including a repeated CT scan that showed intestinal perforation with free air, which was later confirmed in an emergency operation. However, it is emphasized that surgical exploration could have been performed more promptly if more attention had been paid to clinical findings for diagnosis, rather than to merely image changes.
Case report A 63-year-old male with a medical history of known left inguinal hernia, chronic alcoholism and chronic hepatitis sustained direct contusion from a bicycle seat to the left inguinal area while in a collision accident with a motorcycle. About 1 hour later, he presented to our emergency department (ED), and was found to have intense pain in the left hypogastrium, associated with intense sweating. On arrival, he showed the following vital signs: AL 8697 rate 98beats/minute; respiratory rate 16breaths/minute; blood pressure 116/82mmHg, and temperature 35.5°C. On physical examination, there was a reducible left inguinal hernia, with no ecchymosis on the abdominal wall. Bowel sounds were normoactive, but tenderness on the lower abdomen was noted. A plain abdominal (X-ray) film revealed no free air. An initial Focus Assessment Sonography for Trauma (FAST) was carried out and no fluid accumulation was found. His laboratory data showed: white blood cell count 9300 permm3; hematocrit 40.8%; serum creatinine 1.16mg/dL; blood urea nitrogen 16mg/dL; amylase 73IU/L; lipase 49IU/L; aspartate aminotransferase 50IU/L, and alanine aminotransferase 61IU/L. Abdominal computed tomography (CT) was performed soon after arrival and showed no dilatation of the small bowel, no intraperitoneal fluid, and a left inguinal hernia, with partial protrusion of the ileum inside the hernia sac without evidence of free air or fluid (Fig. 1). Considering that the patient was showing persisting intense abdominal pain, he was observed at the ED ward. Eight hours later, the patient developed hypotension, fever and persistent abdominal pain. Reexamination of the abdomen showed muscle guarding, and absence of bowel sounds. Hemodynamic data were stable after fluid infusion, and the repeated abdominal CT showed free air in the hernia sac and peritoneal cavity, associated with bowel edema and fluid accumulation (Fig. 2). An emergency laparotomy was performed, which revealed partial protrusion of the ileum into the hernia sac and three perforations with turbid fluid spreading into the lower intraperitoneal area. The intestine was resected with end-to-end anastomosis; a peritoneal cavity lavage was performed. The inguinal hernia was also repaired intraperitoneally without mesh. The postoperative course was unremarkable. The patient was discharged 2 weeks later. The outpatient follow-up 2 weeks later showed that he had gradually resumed his regular activities.
Discussion The most frequent abdominal wall hernia is inguinal hernia, which accounts for up to 75% of hernias occurring in 27% of men and 3% of women during their lifetime. Of the complications of inguinal hernia, strangulation and incarceration are the most commonly encountered, which lead to obstruction and perforation. There have been rare reports of intra-hernia small bowel perforation following blunt abdominal trauma. In patients with a pre-existing intestine falling into the inguinal hernia, in particular, perforation of the intestine can follow blunt trauma to the abdomen or inguinal region even in low-speed vehicle crashes.