American Journal of Emergency Medicine 33 (2015) 986.e1–986.e2
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Acute sigmoid diverticulitis within a nonincarcerated hernia Abstract Separately, diverticulitis and inguinal hernias are both common findings in emergency medicine. However, diverticulitis within a reducible hernia has not been previously reported. We present a case of sigmoid diverticulitis within a nonincarcerated easily reducible hernia treated with conservative management. Our review of literature did not reveal any previously documented cases of this type of presentation. Separately, diverticulitis and inguinal hernias are both common findings in emergency medicine. However, diverticulitis within a reducible hernia has not been previously reported. Although inguinal hernias most often contain small bowel, the contents are highly variable. In previous reports, a vermiform appendix within an inguinal sac occurs in 1% of inguinal hernias and 0.1% of cases of appendicitis and is called Amyand's hernia [1]. There are documented cases of diverticular abscesses [2], sigmoid carcinoma [3], and a single case report of diverticulitis presenting within an incarcerated inguinal hernia [4]. We present a case of sigmoid diverticulitis within a nonincarcerated easily reducible hernia treated with conservative management. Our review of literature did not reveal any previously documented cases of this type of presentation. A 39-year-old man presented to the emergency department (ED) with the complaint of “My belly button is popping out.” The patient stated that while he noticed a bulge at his umbilicus for about 5 months, it became painful over the past 2 weeks. The patient endorsed frequent heavy lifting with his job in a warehouse and noted that lifting increased his pain. Aside from pain, his only other associated symptom was diarrhea. He denied any previously diagnosed hernias or any other medical problems. He reported a remote history of vasectomy but denied any other surgical history. Physical examination revealed a moderately overweight male with a small umbilical hernia that was soft and reducible, with slight overlying erythema. The patient reported mild lower abdominal pain with palpation but had no rebound tenderness or guarding. On further examination, left-sided inguinal hernia was felt with having the patient cough. This hernia was soft, not discolored, and very easily reducible but much more tender than expected on examination. Complete blood count and electrolytes were both within normal limits. On computed tomographic (CT) imaging, diverticulitis of the descending and sigmoid colon was seen. A small portion of the sigmoid colon wall with diverticulitis and associated fat stranding extended into the left inguinal hernia (Figs. 1 and 2). Conservative management with intravenous fluid, antibiotics, and pain management was initiated. Surgical consultation was obtained. Surgery recommended outpatient conservative management of the
0735-6757/© 2014 Elsevier inc. All rights reserved.
patient's diverticulitis with plans for eventual hernia repair, once the inflammation had resolved. The patient was called 4 days after his ED visit and stated he was doing well, he stated his pain had improved, and he had no additional symptoms. The patient was scheduled for an outpatient appointment with the general surgery clinic with repair scheduled for a later date. The patient was safely managed with conservative therapy for diverticulitis. Thankfully, the unusually tender yet reducible hernia on physical examination prompted CT imaging, which revealed diverticulitis, and this was not misdiagnosed as a painful but reducible hernia. We hope that this case report adds to the growing body of knowledge concerning the possibility of inflamed diverticular colon within painful inguinal hernias. This case helps to point out that hernias may not be a simple presentation and, if there is any suspicion of something unusual, the possibility of an unusual presentation of diverticulitis or other inflammatory inciting process could be present and lead to further investigation. The treatment in this case included antibiotics and fluids, which may not have been done otherwise. Inguinal hernias have been associated with intestinal pathology including inflamed appendices (Amyand's hernia) [1] and Meckel's diverticuli (Littre's hernia) [5]. A diverticular abscess in an incarcerated hernia [2] carcinoma of the sigmoid colon [3] and diverticulitis [4] have been reported in incarcerated hernias as rare isolated, single case–reported events. Our case is unique in presenting a reducible hernia with the additional complication of acute diverticulitis within the reducible hernia. Conservative treatment proved sufficient in this case. The patient's pain was reduced, and the hernia can be repaired routinely in the nonemergent setting. The patient's presentation was similar to that of a reducible inguinal hernia; however, a CT was ordered due to the nature of the pain before reduction of the hernia. This case report demonstrates another possible pathology within an inguinal hernia. Treatment was different than a simple reducible inguinal hernia, as the acute diverticulitis required treatment. This was successfully implemented without requiring an acute surgery and the possible consequences. This diagnosis should be considered in the differential in a patient with a painful inguinal hernia, and imaging, considered in such cases.
Nicholas Arnold, PA Amy A. Ernst, MD ⁎ Department of Emergency Medicine University of New Mexico, Albuquerque, NM ⁎Corresponding author http://dx.doi.org/10.1016/j.ajem.2014.12.022
986.e2
N. Arnold, A.A. Ernst / American Journal of Emergency Medicine 33 (2015) 986.e1–986.e2
References [1] Michalinos A, Moris D, Vernadakis S. Amyand's hernia: a review. Am J Surg 2014;207: 989–95. [2] Greenberg J, Arnell TD. Diverticular abscess presenting as an incarcerated inguinal hernia. Am Surg 2005;71:208–9. [3] Ruiz-Tovar J, Ripalda E, Beni R, Nistal J, Monroy C, Carda P. Carcinoma of the sigmoid colon in an incarcerated inguinal hernia. Can J Surg 2009;52:E31–2. [4] Kajese TM, Beamer RL. Acute sigmoid diverticulitis within an incarcerated inguinal hernia in an adult: a first report. Am Surg 2014;79:E147–8. [5] Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Littre hernia: surgical anatomy, embryology, and technique of repair. Am Surg 2006;72:238–43.
Fig. 1. Axial CT slice demonstrating small diverticular air pouches and fat stranding (arrow) extending into a left inguinal hernia defect. There were no abscesses or dilated loops of bowel appreciated.
Fig. 2. Coronal CT slice demonstrating diverticular pouches, thickened bowel wall, and associated fat stranding that partially extend into left inguinal hernia defect.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Acute sigmoid diverticulitis within a nonincarcerated hernia Abstract Separately, diverticulitis and inguinal hernias are both common findings in emergency medicine. However, diverticulitis within a reducible hernia has not been previously reported. We present a case of sigmoid diverticulitis within a nonincarcerated easily reducible hernia treated with conservative management. Our review of literature did not reveal any previously documented cases of this type of presentation. Separately, diverticulitis and inguinal hernias are both common findings in emergency medicine. However, diverticulitis within a reducible hernia has not been previously reported. Although inguinal hernias most often contain small bowel, the contents are highly variable. In previous reports, a vermiform appendix within an inguinal sac occurs in 1% of inguinal hernias and 0.1% of cases of appendicitis and is called Amyand's hernia [1]. There are documented cases of diverticular abscesses [2], sigmoid carcinoma [3], and a single case report of diverticulitis presenting within an incarcerated inguinal hernia [4]. We present a case of sigmoid diverticulitis within a nonincarcerated easily reducible hernia treated with conservative management. Our review of literature did not reveal any previously documented cases of this type of presentation. A 39-year-old man presented to the emergency department (ED) with the complaint of “My belly button is popping out.” The patient stated that while he noticed a bulge at his umbilicus for about 5 months, it became painful over the past 2 weeks. The patient endorsed frequent heavy lifting with his job in a warehouse and noted that lifting increased his pain. Aside from pain, his only other associated symptom was diarrhea. He denied any previously diagnosed hernias or any other medical problems. He reported a remote history of vasectomy but denied any other surgical history. Physical examination revealed a moderately overweight male with a small umbilical hernia that was soft and reducible, with slight overlying erythema. The patient reported mild lower abdominal pain with palpation but had no rebound tenderness or guarding. On further examination, left-sided inguinal hernia was felt with having the patient cough. This hernia was soft, not discolored, and very easily reducible but much more tender than expected on examination. Complete blood count and electrolytes were both within normal limits. On computed tomographic (CT) imaging, diverticulitis of the descending and sigmoid colon was seen. A small portion of the sigmoid colon wall with diverticulitis and associated fat stranding extended into the left inguinal hernia (Figs. 1 and 2). Conservative management with intravenous fluid, antibiotics, and pain management was initiated. Surgical consultation was obtained. Surgery recommended outpatient conservative management of the
0735-6757/© 2014 Elsevier inc. All rights reserved.
patient's diverticulitis with plans for eventual hernia repair, once the inflammation had resolved. The patient was called 4 days after his ED visit and stated he was doing well, he stated his pain had improved, and he had no additional symptoms. The patient was scheduled for an outpatient appointment with the general surgery clinic with repair scheduled for a later date. The patient was safely managed with conservative therapy for diverticulitis. Thankfully, the unusually tender yet reducible hernia on physical examination prompted CT imaging, which revealed diverticulitis, and this was not misdiagnosed as a painful but reducible hernia. We hope that this case report adds to the growing body of knowledge concerning the possibility of inflamed diverticular colon within painful inguinal hernias. This case helps to point out that hernias may not be a simple presentation and, if there is any suspicion of something unusual, the possibility of an unusual presentation of diverticulitis or other inflammatory inciting process could be present and lead to further investigation. The treatment in this case included antibiotics and fluids, which may not have been done otherwise. Inguinal hernias have been associated with intestinal pathology including inflamed appendices (Amyand's hernia) [1] and Meckel's diverticuli (Littre's hernia) [5]. A diverticular abscess in an incarcerated hernia [2] carcinoma of the sigmoid colon [3] and diverticulitis [4] have been reported in incarcerated hernias as rare isolated, single case–reported events. Our case is unique in presenting a reducible hernia with the additional complication of acute diverticulitis within the reducible hernia. Conservative treatment proved sufficient in this case. The patient's pain was reduced, and the hernia can be repaired routinely in the nonemergent setting. The patient's presentation was similar to that of a reducible inguinal hernia; however, a CT was ordered due to the nature of the pain before reduction of the hernia. This case report demonstrates another possible pathology within an inguinal hernia. Treatment was different than a simple reducible inguinal hernia, as the acute diverticulitis required treatment. This was successfully implemented without requiring an acute surgery and the possible consequences. This diagnosis should be considered in the differential in a patient with a painful inguinal hernia, and imaging, considered in such cases.
Nicholas Arnold, PA Amy A. Ernst, MD ⁎ Department of Emergency Medicine University of New Mexico, Albuquerque, NM ⁎Corresponding author http://dx.doi.org/10.1016/j.ajem.2014.12.022
986.e2
N. Arnold, A.A. Ernst / American Journal of Emergency Medicine 33 (2015) 986.e1–986.e2
References [1] Michalinos A, Moris D, Vernadakis S. Amyand's hernia: a review. Am J Surg 2014;207: 989–95. [2] Greenberg J, Arnell TD. Diverticular abscess presenting as an incarcerated inguinal hernia. Am Surg 2005;71:208–9. [3] Ruiz-Tovar J, Ripalda E, Beni R, Nistal J, Monroy C, Carda P. Carcinoma of the sigmoid colon in an incarcerated inguinal hernia. Can J Surg 2009;52:E31–2. [4] Kajese TM, Beamer RL. Acute sigmoid diverticulitis within an incarcerated inguinal hernia in an adult: a first report. Am Surg 2014;79:E147–8. [5] Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Littre hernia: surgical anatomy, embryology, and technique of repair. Am Surg 2006;72:238–43.
Fig. 1. Axial CT slice demonstrating small diverticular air pouches and fat stranding (arrow) extending into a left inguinal hernia defect. There were no abscesses or dilated loops of bowel appreciated.
Fig. 2. Coronal CT slice demonstrating diverticular pouches, thickened bowel wall, and associated fat stranding that partially extend into left inguinal hernia defect.
