CASE 14621 Published on 25.04.2017

Teaching Case

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

"Luigi Sacco" University Hospital,
Radiology Department;
Via G.B. Grassi 74
20157 Milan, Italy;
Email:mtonolini@sirm.org

Patient

65 years, male

Categories

Area of Interest Abdominal wall ; Imaging Technique CT ;

Procedure Diagnostic procedure, Dilation ; Special Focus Hernia ;

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Clinical History

65-year-old male patient with alcohol-related liver cirrhosis, two-year history of refractory ascites despite diuretics, and previous inguinal hernioplasty. Currently complains of skin ulceration at the site of the umbilical hernia. Physically found afebrile, with distended non-tender abdomen and normal vital signs. Laboratory assays revealed mild anaemia, platelet count and C-reactive protein within normal limits.

Differential Diagnosis List

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Spontaneous leakage of ascites from umbilical hernia in cirrhosis.

Spontaneous bacterial peritonitis

Hernia rupture after trauma

Coughing

Vomiting

Umbilical hernia with herniated abdominal organ(s)

Umbilical hernia with visceral strangulation or omental necrosis

Imaging Findings

One year earlier, multiphase CT (Fig. 1) had shown cirrhotic liver without focal lesions suspicious for hepatocellular carcinoma and abundant ascites, a right-sided inguinal hernia and round-shaped, externally convex umbilical hernia with narrow neck and continuous, uniform hernial sac including the peritoneal serosa; both hernias were filled by ascitic fluid without herniated viscera. Shortly thereafter, he underwent uncomplicated inguinal hernioplasty using prosthetic mesh.
Currently on treatment with diuretics, intravenous albumin and antibiotics because of incipient portosystemic encephalopathy, the patient suddenly experienced spontaneous leakage of ascites through the umbilical hernia. Repeated CT (Fig. 2) showed mild decrease of ascites, collapsed umbilical hernia concave outer border of hernial sac, thinned skin overlying the enhancing peritoneal serosa. Microscopy and culture of ascitic fluid revealed leukocytosis (800 cells/mmc, 82% polymorphonucleates), no malignant cells, positive cultures for methicillin-resistant Staphylococcus aureus consistent with spontaneous bacterial peritonitis. Surgical repair of umbilical hernia was ultimately performed.

Discussion

Umbilical hernias (UHs) are commonly encountered in patients affected with liver cirrhosis, particularly when longstanding ascites in present; conversely, inguinal hernias are not markedly influenced by liver decompensation. At the site of the UH, peritoneal serosa, preperitoneal fat and ascitic fluid generally protrude through the umbilical ring. Unfortunately, UHs exposed patients to potentially life-threatening complications such as visceral or omental incarceration and strangulation (which is often precipitated by rapid removal of fluid through paracentesis), hernial ulceration and rupture [1, 2].
Spontaneous ascitic leakage (SAL) is almost invariably associated with alcoholism because of unknown reasons, is generally preceded by skin ulceration overlying the UH, and develops through a breach of the hernial sac and peritoneum. Currently very uncommon because of improved standards of care, SAL may result in high-volume paracentesis, represents a risk factor for adverse outcome and is associated with 5-30% mortality rate from peritonitis, sepsis or liver failure [3-6].
As seen in the hereby presented case, the use of CT including multiplanar reformations is very helpful in patients with distended abdomen and limited physical examination: CT allows confirming the presence and assess contents of an UH in the setting of cirrhosis, and to differentiate SAL from other potential complications such as omental necrosis secondary to torsed vascular pedicle, incarceration or strangulation of abdominal viscera [7].
Therefore, currently early surgical repair of UH is recommended, as non-operative treatment is associated with subsequent hernia repair in emergency setting and high mortality. Elective repair using prosthetic mesh after antibiotic prophylaxis, control of ascites, improved coagulation, metabolic and nutritional status allows preventing further complications with limited morbidity. Many centres suggest metabolic optimization using transjugular intrahepatic portosystemic shunt (TIPS) before umbilical hernioplasty [1, 8-11].

References

[1] Belghiti J, Durand F (1997) Abdominal wall hernias in the setting of cirrhosis. Semin Liver Dis 17:219-226 (PMID: 9308126)

[2] Lemmer JH, Strodel WE, Knol JA, et al (1983) Management of spontaneous umbilical hernia disruption in the cirrhotic patient. Ann Surg 198:30-34 (PMID: 6859990)

[3] Ferreira AO, Marinho RT, Ramalho F, et al (2013) Ascitic eruption in an umbilical hernia in cirrhosis. BMJ Case Rep doi: 10.1136/bcr-2012-007741 (PMID: 23283619)

[4] MacLellan DG, Watson KJ, Farrow HC, et al (1990) Spontaneous paracentesis following rupture of an umbilical hernia. Aust N Z J Surg 60:555-556 (PMID: 2357184)

[5] Martens PJ, Laleman W (2015) Umbilical hernia in a patient with cirrhosis. Cleve Clin J Med 82:404-405. (PMID: 26185937)

[6] Podymow T, Sabbagh C, Turnbull J (2003) Spontaneous paracentesis through an umbilical hernia. Cmaj 168:741. (PMID: 12642434)

[7] Aguirre DA, Santosa AC, Casola G, et al (2005) Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 25:1501-1520 (PMID: 16284131)

[8] Marsman HA, Heisterkamp J, Halm JA, et al (2007) Management in patients with liver cirrhosis and an umbilical hernia. Surgery 142:372-375 (PMID: 17723889)

[9] McKay A, Dixon E, Bathe O, et al (2009) Umbilical hernia repair in the presence of cirrhosis and ascites: results of a survey and review of the literature. Hernia 13:461-468 (PMID: 19652907)

[10] Triantos CK, Kehagias I, Nikolopoulou V, et al (2011) Surgical repair of umbilical hernias in cirrhosis with ascites. Am J Med Sci 341:222-226. (PMID: 20890175)

[11] Youssef YF, El Ghannam M (2007) Mesh repair of non-complicated umbilical hernia in ascitic patients with liver cirrhosis. J Egypt Soc Parasitol 37:1189-1197 (PMID: 18431993)

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