Images Bashir Antoine Chakar (Emergency Registrar) and text Genevieve Carbonatto
A 72 year old man presents to the Emergency Department. He awoke in the early hours of the morning with acute abdominal pain which he thinks is due to what he had eaten the night before. He describes his pain as being 10/10. He has been treated in the past for peptic ulcer disease and gastritis. He has been seen by your colleague who thinks this may be reflux oesophagitis. He is treated for this but despite analgesia he does not settle. His CRP is 3.2, his WCC 9.2, his electrolytes unremarkable. You are asked to do an ultrasound to check whether anything else may be going on.
This is his right upper quadrant. Note the significant free fluid in the abdomen, visible here between the liver and the diaphragm.
This is his ultrasound suprapubically
Here the contents of the small bowel can be seen moving to and fro within the lumen. The bowel wall is thickened and the valvulae conniventes are also very thickened and oedematous causing a “lace like effect” There is a lot of free fluid within the peritoneal cavity.
A close up of the loops of bowel shows a ‘lace like’ bowel wall due to the thickened valvulae conniventes. This is typical of bowel oedema.
You immediately call the surgeons. A CT is organised and the report states that there is no free fluid in the peritoneal cavity and mild bowel wall thickening in the right lower quadrant. He is urgently taken to theatre where an internal hernia is identified and 500 mls of serosanguinous fluid is evacuated. 160 cm of congested hyperaemic bowel is visible. The internal hernia is reduced. The bowel is still viable and treated with warm packs and oxygen and after a short stint in ICU on antibiotics he is discharged for rehabilitation and does well.
Misdiagnosis or delayed diagnosis of internal hernias is common. This delay in diagnosis causes significant morbidity and mortality (1)
In a previous post ( see :I think he has gastro) we had a young boy who presented with abdominal pain and the diagnosis was supposed to be gastroenteritis. He also had an internal hernia. His abdominal ultrasound changed the course of his management and urgent surgery provided a good outcome. The same applies in this case. The working diagnosis was dramatically changed with ultrasound and a satisfactory outcome obtained with surgery. Note that in this second case the CT scan did not properly diagnose or give a sense of the urgency of this surgical emergency. Note that in both cases the ultrasound showed significant free fluid within the abdomen, due to the bowel oedema and ischaemia.
This is a summary of some salient features of the article by Hizir Akyildiz from the Internal Journal of surgery on internal hernias.
- An internal hernia is defined as a protrusion of a viscus, usually the small bowel through a normal or abnormal peritoneal or mesenteric aperture within the abdominal and pelvic cavity
- Overall incidence of <1%
- Cause 0.6 to 5.8% of all small bowel obstructions
- Can be acquired or congenital
- Delay to surgery can be significant as small bowel obstruction is diagnosed on CT or Xray but the internal hernia is not diagnosed, so patients can be on the wards for days with a “wait and see” approach to management.
In their series of 25 patients there was a 36% rate of mortality with the delay to surgery or more than 3 days being the determining factor for both morbidity and mortality
Teaching point: All undifferentiated abdominal pain should have an abdominal ultrasound in the Emergency Department. The ability to potentiate timely diagnosis and management is central to our practice as Emergency Physicians. Keep an open mind about CT scans. They may not always be the gold standard.
- International Journal of Surgery ,7 (2009) 334–337:Internal hernia: Complex diagnostic and therapeutic problem Hizir Akyildiz a,*, Tarik Artis a, Erdogan Sozuer a, Alper Akcan a, Can Kucuk a, Emine Sensoy a,Ibrahim Karahan b