Answer for BIR CoW 15 Oct 2023
Umbilical hernia with obstruction
Findings
Evidence of multiple dilated small bowel loops with air fluid level noted in jejunum and proximal ileal bowel with max diameter 3.2 cm. E/O 1.9 cm defect noted in umbilical region with herniation of dilated small bowel loops and free fluid as content. E/O multiple calcified nodules in omentum with surrounding fat standing noted. Free fluid noted in abdomen and pelvis. Bilateral ovaries appear enlarged with internal calcification.
Discussion
F/S/O Obstructive umbilical hernia with small bowel and free fluid as content. Moderate Ascites. DISCUSSION: An abdominal wall hernia occurs when a portion of the bowel or peritoneum extends beyond the abdominal wall, resulting in a sac containing tissue or abdominal organs. Hernias can be classified as inguinal, femoral, incisional, umbilical, or epigastric . The most common ventral hernia is the umbilical hernia .An umbilical hernia occurs due to a defect in the anterior abdominal wall 3 cm above or below the umbilicus This abdominal defect is common among patients with increased intra-abdominal pressure due to pregnancy, ascites, or obesity, which weakens the abdominal musculature. Common complications of Umbilical hernias include small bowel obstruction (SBO) and bowel ischemia An Small bowel Obstruction is defined as a complete or partial blockage of the small intestine due to a functional or mechanical pathology . This presents as abdominal pain, distension, nausea, vomiting, constipation, and high-pitched or absent bowel sounds. Further complications include hernia incarceration (irreducible sac) and strangulation (ischemia secondary to lack of blood supply) . The use of CT imaging helps identify subtle signs of complications such as obstruction, incarceration, and strangulation. On CT imaging, key findings of an SBO include small bowel dilation, a transition point from dilated to nondilated small bowel, colon compression, and air-fluid levels. CT imaging demonstrates the umbilical hernia containing a portion of the small bowel in a C-shaped configuration. Narrowing of the hernial sac neck in addition to fat stranding on CT imaging also suggests hernia incarceration and inflammatory changes Other associated findings of SBO secondary to a strangulated umbilical hernia include discrete mesenteric engorgement, ascitic fluid within the hernia sac, and dilation of herniated bowel loops . Most cases of strangulated obstruction are related to closed-loop obstruction. Whirl sign - convergence of mesenteric vessels toward the twisted site, and reversed position of the mesenteric artery and vein; Serrated beak sign - indicates the presence of a closed loop associated with regional mesenteric vascular engorgement, as well as bowel wall thickening at the obstructed bowel; this sign also suggests strangulated obstruction The proposed well-known diagnostic CT criteria for strangulated obstruction are: • pneumatosis intestinalis • Abnormal bowel wall enhancement • Serrated beak sign • Diffuse mesenteric vascular engorgement and haziness • Bowel wall thickening • A large amount of ascites
Findings
Evidence of multiple dilated small bowel loops with air fluid level noted in jejunum and proximal ileal bowel with max diameter 3.2 cm. E/O 1.9 cm defect noted in umbilical region with herniation of dilated small bowel loops and free fluid as content. E/O multiple calcified nodules in omentum with surrounding fat standing noted. Free fluid noted in abdomen and pelvis. Bilateral ovaries appear enlarged with internal calcification.
Discussion
F/S/O Obstructive umbilical hernia with small bowel and free fluid as content. Moderate Ascites. DISCUSSION: An abdominal wall hernia occurs when a portion of the bowel or peritoneum extends beyond the abdominal wall, resulting in a sac containing tissue or abdominal organs. Hernias can be classified as inguinal, femoral, incisional, umbilical, or epigastric . The most common ventral hernia is the umbilical hernia .An umbilical hernia occurs due to a defect in the anterior abdominal wall 3 cm above or below the umbilicus This abdominal defect is common among patients with increased intra-abdominal pressure due to pregnancy, ascites, or obesity, which weakens the abdominal musculature. Common complications of Umbilical hernias include small bowel obstruction (SBO) and bowel ischemia An Small bowel Obstruction is defined as a complete or partial blockage of the small intestine due to a functional or mechanical pathology . This presents as abdominal pain, distension, nausea, vomiting, constipation, and high-pitched or absent bowel sounds. Further complications include hernia incarceration (irreducible sac) and strangulation (ischemia secondary to lack of blood supply) . The use of CT imaging helps identify subtle signs of complications such as obstruction, incarceration, and strangulation. On CT imaging, key findings of an SBO include small bowel dilation, a transition point from dilated to nondilated small bowel, colon compression, and air-fluid levels. CT imaging demonstrates the umbilical hernia containing a portion of the small bowel in a C-shaped configuration. Narrowing of the hernial sac neck in addition to fat stranding on CT imaging also suggests hernia incarceration and inflammatory changes Other associated findings of SBO secondary to a strangulated umbilical hernia include discrete mesenteric engorgement, ascitic fluid within the hernia sac, and dilation of herniated bowel loops . Most cases of strangulated obstruction are related to closed-loop obstruction. Whirl sign - convergence of mesenteric vessels toward the twisted site, and reversed position of the mesenteric artery and vein; Serrated beak sign - indicates the presence of a closed loop associated with regional mesenteric vascular engorgement, as well as bowel wall thickening at the obstructed bowel; this sign also suggests strangulated obstruction The proposed well-known diagnostic CT criteria for strangulated obstruction are: • pneumatosis intestinalis • Abnormal bowel wall enhancement • Serrated beak sign • Diffuse mesenteric vascular engorgement and haziness • Bowel wall thickening • A large amount of ascites
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!