An 85-year-old woman presented with central abdominal pain and vomiting.
Clinical exam reveals a large tender midline upper abdominal mass, there was suspicion for an epigastric hernia.
An abdominal CT is performed
Describe and interpret the CT scan
The CT demonstrates a midline abdominal wall hernia, located in the epigastrium.
There is a narrow defect in the abdominal wall, and herniation of a short loop of small bowel.
The herniating bowel is narrowed at both ends, resulting in a closed loop obstruction.
In this case there is normal enhancement of the small bowel, however this can rapidly progress to gangrene with hypo-enhancement of the wall and further subsequent bowel perforation.
There is also proximal small bowel loop dilatation due to obstruction.
There are many different types of ventral hernias (image), both midline and lateral.
Common midline hernias include umbilical, paraumbilical, and incisional.
An epigastric hernia, is the least common type of midline hernia, occurring in only 2-3% of cases.
It is a hernia occurring along the linear alba between the xiphoid and the umbilicus.
These are more commonly seen in middle aged men and obese patients. Risk factors as with other hernias include coughing and heavy lifting.
As epigastric hernias tend to be small defects, they have a higher tendency for incarceration. Usually, epigastric hernias will only contain pre-peritoneal fat or omentum. It is particularly rare, as in this case, for an epigastric hernia to contain intra-abdominal viscera.
This patient underwent surgical repair. The incarcerated small bowel and omentum were viable and able to be reduced with primary closure of the hernial deficit.
- Ford DW. Hernia Repair
TOP 100 CT SERIES
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.
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).