CASE 16445 Published on 13.09.2019

Epiploic appendices in a femoral hernia

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

John David Spillane1, Paul Carruthers2

1 University Hospitals Bristol NHS Foundation Trust, Bristol, UNITED KINGDOM
2 Southmead Hospital North Bristol Trust

Patient

59 years, female

Categories
Area of Interest Abdomen, Colon, Gastrointestinal tract ; Imaging Technique CT
Clinical History

A 59-year-old female presented with a 5-day history of abdominal pain. She denied vomiting or constipation. She was systemically well, her bloods were normal, and on examination was found to have a small irreducible lump in her left groin. Further assessment with cross sectional imaging was requested.

Imaging Findings

On the subsequent post-contrast portal-venous phase CT abdomen and pelvis, there was a small fat containing sac with a funnel shaped neck protruding inferiorly to the left inguinal ligament and lateral to the pubic tubercle. The fat in the sac was inflamed and was arising from the anti-mesenteric border of the sigmoid colon. It did not contain any bowel or other viscera. Around the sac was surrounding fat stranding with compression of the ipsilateral femoral vein.

Discussion

Femoral hernias are a type of groin hernia where there is a protrusion of a peritoneal sac, which may contain peritoneal fat, omentum, small bowel or other viscera, through the femoral ring into the femoral canal. Differentiating femoral from inguinal hernias is difficult, but important as they are more likely to strangulate and require different surgical approaches [1-3].
Features seen on CT to help differentiate femoral from inguinal hernias include 1.) They arise inferior to the inguinal ligament, 2.) They do not pass medial to the pubic tubercle, 3.) The sac has a characteristic funnel shaped neck, and 4.) There is a higher incidence of femoral vein compression [1-3].
Epiploic appendices is a rare, self-limiting inflammatory/ischaemic process involving an appendix epiploica of the colon, which are small adipose protrusions from the serosal surface of the colon that undergo torsion or secondary inflammation [4,5]. This condition is most common in obese patients and women in their 5th decade, and typically present as acute abdominal pain [5]. It is a well-known mimic for other acute abdominal pathologies such as appendicitis or acute diverticulitis. However, as this condition is self-limiting it does not require surgical intervention [4,5].
For the clinical team, their main concern and purpose for imaging a patient with acute abdominal pain and an irreducible groin lump is to ensure that there isn’t a strangulated bowel containing groin hernia causing obstruction, as this would require emergency surgery. The CT was useful as it confirmed the presence of a hernia, but with no bowel within it and demonstrated an alternative cause for her pain.
Epiploic appendiceswithin a groin hernia is a rare occurrence with more case studies involving inguinal hernias. But it is important to be aware of, as it can mimic a strangulated hernia and would be more likely to have an emergency repair rather than elective repair, which tends to have more complications. As fat could be seen entering the hernia from the ante-mesenteric border it is a useful sign to suggest the diagnosis.
Because the patient was systemically well and her imaging provided an alternative cause for the pain, she was discharged with follow-up to have an elective femoral hernia repair due to the high potential future risk of strangulation.
Key messages : 1.) Ensure there is no other cause for inflammatory change within or around a hernia, such as an epiploic appendices, 2.) Try to differentiate inguinal from femoral hernias.

Written informed patient consent for publication has been obtained.

Differential Diagnosis List
Epiploic appendices in a femoral hernia
Incarcerated fat containing inguinal hernia
Final Diagnosis
Epiploic appendices in a femoral hernia
Case information
URL: https://www.eurorad.org/case/16445
ISSN: 1563-4086