Figure 1
Figure 1:
Axial contrast-enhanced abdominal CT. A right inguinal hernia (yellow arrow) is shown.
Incarcerated groin Richter´s hernia
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsGarcía-Lallana A1, Noguera JJ1, Martí-Cruchaga P2, Rotellar F2, Saiz-Mendiguren R1, Arraiza M1. 1Radiology Department, 2 General Surgery Department, University Clinic of Navarra, Pamplona, Spain.
Connected authors
78 years, male
Clinical History
This patient came to our emergency set suffering from epigastric, right side and right groin pain. A contrast-enhanced abdominal CT was performed. The origin of pain was a small bowel obstruction due to a Richter hernia. Besides, a sigmoid colon neoplasm with liver metastases was discovered.
Imaging Findings
We present the case of a 78 year old male patient with prior right inguinal herniorrhaphy 53 years ago, who presented with pain in his left flank, vomiting and food intolerance. He referred two days of constipation.
Abdominal radiography series demonstrated an “image stack of coins” with lack of gas in colon. These findings led to diagnosis of small bowel obstruction. An abdominal CT showed an incarcerated right inguinal hernia (Fig. 1). This caused a great retrograde distension of the small bowel and stomach (Fig. 2) and an urgent surgical reduction was performed. CT also demonstrated sigmoid stenosing neoplasia (Fig. 3) and several liver metastases (Fig. 4).
A chest CT was performed with no signs of metastatic spread. Only some millimetre sized lung nodules were found, accompanied by bilateral mediastinal adenopathies that could be related to granulomatous inflammatory post-exposure disease (silicosis).
Laparoscopic surgical reduction was performed. Only the antimesenteric margin of a small bowel loop was herniated through the right deep groin ring. This finding gave the diagnosis of Richter groin hernia.
After hernia reduction, treatment was initiated with the scheme Capecitabine-Cetuximab for two cycles, the sigmoidectomy was performed.
Abdominal radiography series demonstrated an “image stack of coins” with lack of gas in colon. These findings led to diagnosis of small bowel obstruction. An abdominal CT showed an incarcerated right inguinal hernia (Fig. 1). This caused a great retrograde distension of the small bowel and stomach (Fig. 2) and an urgent surgical reduction was performed. CT also demonstrated sigmoid stenosing neoplasia (Fig. 3) and several liver metastases (Fig. 4).
A chest CT was performed with no signs of metastatic spread. Only some millimetre sized lung nodules were found, accompanied by bilateral mediastinal adenopathies that could be related to granulomatous inflammatory post-exposure disease (silicosis).
Laparoscopic surgical reduction was performed. Only the antimesenteric margin of a small bowel loop was herniated through the right deep groin ring. This finding gave the diagnosis of Richter groin hernia.
After hernia reduction, treatment was initiated with the scheme Capecitabine-Cetuximab for two cycles, the sigmoidectomy was performed.
Discussion
Abdominal wall hernias are a common abdominal disease. Although most of them are asymptomatic, some acute complications may develop as intestinal obstruction, incarceration, strangulation or even traumatic rupture [1].
Richter´s hernia was first described in 1598 [2] as a type of incarcerated hernia with strangulation of only a portion of the circumference of the intestinal wall [1]. It is a very rare disease so its diagnosis remains difficult and it associates with high morbidity and mortality rate [3].
Clinical manifestations are unspecific, and include abdominal distension, pain, dehydration, constipation, vomiting and general malaise. It indiscriminately affects both men and women, especially in their sixties or older, and are often unilateral [3].
They may occur in any location but the most common sites are the femoral and inguinal regions, although there are also reported cases in relation to defects in abdominal wall after laparoscopic surgery [3]. The presence of a rigid ring in the rupture contributes to a high risk of incarceration or strangulation, which may cause ischemia of the part of the involved bowel [3]. These complications may occur without bowel obstruction, leading to a delay in diagnosis [3].
The prognosis of this disease could be improved by its inclusion in the differential diagnosis of acute abdomen, especially in those patients with prior surgical treatments [2]. The presence of signs of obstruction in an abdominal X-ray series, although unspecific, may lead to suspicion of this disease. CT is the most diagnostic tool for Richter´s hernia [1] and also provides information about the status of the bowel loops.
In our case, the performance of an abdominal CT not only enabled us to diagnose this type of hernia, but also discovered that the patient suffered from sigmoid neoplasia with liver metastases. It is of utmost importance to perform a systematic CT reading. In this particular case, sigmoid neoplasia might have passed unnoticed. Liver metastases led to suspicion of abdominal neoplasia.
Richter´s hernia was first described in 1598 [2] as a type of incarcerated hernia with strangulation of only a portion of the circumference of the intestinal wall [1]. It is a very rare disease so its diagnosis remains difficult and it associates with high morbidity and mortality rate [3].
Clinical manifestations are unspecific, and include abdominal distension, pain, dehydration, constipation, vomiting and general malaise. It indiscriminately affects both men and women, especially in their sixties or older, and are often unilateral [3].
They may occur in any location but the most common sites are the femoral and inguinal regions, although there are also reported cases in relation to defects in abdominal wall after laparoscopic surgery [3]. The presence of a rigid ring in the rupture contributes to a high risk of incarceration or strangulation, which may cause ischemia of the part of the involved bowel [3]. These complications may occur without bowel obstruction, leading to a delay in diagnosis [3].
The prognosis of this disease could be improved by its inclusion in the differential diagnosis of acute abdomen, especially in those patients with prior surgical treatments [2]. The presence of signs of obstruction in an abdominal X-ray series, although unspecific, may lead to suspicion of this disease. CT is the most diagnostic tool for Richter´s hernia [1] and also provides information about the status of the bowel loops.
In our case, the performance of an abdominal CT not only enabled us to diagnose this type of hernia, but also discovered that the patient suffered from sigmoid neoplasia with liver metastases. It is of utmost importance to perform a systematic CT reading. In this particular case, sigmoid neoplasia might have passed unnoticed. Liver metastases led to suspicion of abdominal neoplasia.
Differential Diagnosis List
Incarcerated groin Richter´s hernia
Final Diagnosis
Incarcerated groin Richter´s hernia
References
[1] Aguirre DA, Santosa AC, Casola G, et al. (2005) Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 25:1501-20. (PMID: 16284131)
[2] Steinke W, Zellweger R (2000) Richter's hernia and Sir Frederick Treves: an original clinical experience, review, and historical overview. Ann Surg 232:710-8. (PMID: 11066144)
[3] Takeyama N, Gokan T, Ohgiya Y, et al. (2005) CT of internal hernias. Radiographics 25:997-1015. (PMID: 16009820)
[4] Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P (2006) Richter hernia: surgical anatomy and technique of repair. Am Surg 72(2):180-4. (PMID: 16536253)
Case information
| URL: | https://www.eurorad.org/case/7174 |
| DOI: | 10.1594/EURORAD/CASE.7174 |
| ISSN: | 1563-4086 |
Figure 2
Figure 2:
Coronal contrast-enhanced abdominal CT. A large distension of the stomach and small bowel due to a right inguinal Richter´s hernia (yellow arrow) is shown.
Figure 3
Figure 3:
Coronal contrast-enhanced abdominal CT. A sigmoid neoplasia (white arrow) is shown. Dilated small bowel proximal to obstruction (orange arrow) and normal distal bowel (blue arrow) are also shown.
Figure 4
Figure 4:
Axial contrast-enhanced abdominal CT. Liver metastases (green arrows).
Figure 1:
Axial contrast-enhanced abdominal CT. A right inguinal hernia (yellow arrow) is shown.
Figure 2:
Coronal contrast-enhanced abdominal CT. A large distension of the stomach and small bowel due to a right inguinal Richter´s hernia (yellow arrow) is shown.
Figure 3:
Coronal contrast-enhanced abdominal CT. A sigmoid neoplasia (white arrow) is shown. Dilated small bowel proximal to obstruction (orange arrow) and normal distal bowel (blue arrow) are also shown.
Figure 4:
Axial contrast-enhanced abdominal CT. Liver metastases (green arrows).