Case of the Week 2/2/14

A 82yo male with hx of HTN and BPH presented to the ED with intermittent R groin pain x2 weeks.  Pain was described as a discomfort, not pain.  Patient denied dysuria, hematuria, urethral discharge, back/flank pain, or prior surgeries.  He denied any fever, nausea, vomiting, or diarrhea.

Vital Signs: T 95°F  /  P 73  /  BP 175/80  /  RR 20  /  Sat 98%
Exam:
General appearance:  NAD.
Abdominal:  Soft.  Nontender.  Non distended.  Normal bowel sounds.  No organomegaly.  no hernias palpated.
Genitalia:  Within normal limits. On standing, no hernias palpated and no scrotal tenderness. +TTP on R side groin.
Back:  Nontender

U/A: microscopic and macroscopic were normal.

In the ED, a bedside ultrasound revealed inguinal hernia.

 
















Click on the video below to see the actual ultrasound clip of the hernia. You will see the bowel moving in and out as the probe is used to compress the hernia.

Formal U/S (to confirm bedside):
Impression: Right inguinal hernia containing a probable nonobstructed loop of bowel.

Wrap Up: Despite the hernia being hard to palpate on PE, Dr. Scholz used bedside ultrasound over the area of tenderness, and was able to make a more accurate diagnosis without the need for radiation.

Pt was referred to outpatient surgery despite “not wanting surgery.”  He was given strict return precautions regarding incarceration and strangulation symptoms.  Pt understood and agreed.

Review/Discussion:
Inguinal hernia = soft tissue protruding through a weak point in the abdominal muscles
Types of inguinal hernias:

Direct – enters through weak point of fascia of abdominal wall, medial to inferior epigastric vessels


Indirect – enters through patent processus vaginalis, lateral to inferior epigastric vessels


2006 study1: 51 patients with recurrent inguinal pain and negative clinical examinations underwent ultrasound examination.  20 ultrasound-confirmed cases underwent surgery, confirming 19 of the ultrasound diagnoses (100% ultrasound sensitivity, 96.9% specificity).  This study confirmed that ultrasound is capable of accurately diagnosing inguinal hernias without the need for radiation in patients with groin pain but negative physical exams.

1 Lorenzini C, Sofia L, Pergolizzi FP, Trovato M. (2006). The value of diagnostic ultrasound for detecting occult inguinal hernia in patients with groin pain. Chir Ital. 2008 Nov-Dec;60(6):813-7.


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