CT Case 050
A 50-year-old man presents to the emergency department with central abdominal pain, nausea, vomiting and fevers.
Clinical examination demonstrates a very tender and erythematous umbilical mass.
A CT abdomen is performed
Describe and interpret the CT scan
CT interpretation
There is a bowel containing umbilical hernia with surrounding fat stranding.
The dilated small bowel loops are evidence that the hernia is causing small bowel obstruction.
Clinical Pearls
The case demonstrates a complicated umbilical hernia with herniation of small bowel.
Umbilical hernias tend to be narrow necked whereas paraumbilical hernias will have a wider neck. This is an important distinction between the two, as the narrower neck predisposes to incarceration and strangulation.
An incarcerated (also known as irreducible) hernia is a complication in which the contents are unable to pass back through the hernial opening to their anatomical site of origin. As incarceration predisposes to bowel obstruction and strangulation, it necessitates urgent surgery.
Strangulation itself occurs when the hernial opening is so constricted that the arterial supply or venous return are compromised, leading to ischaemia. This can be seen as hypo-enhancement or non-enhancement of the bowel wall, bowel wall thickening, dilatation of the herniated loops and free fluid.
In this case, the hernia has become irreducible and has caused proximal small bowel obstruction due to the luminal narrowing of the herniated loops, however, there are no features of strangulation.
References
- Muysoms FE et al. Classification of primary and incisional abdominal wall hernias. Hernia. 2009 Aug;13(4):407-14.
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Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.