Spigelian Hernia as A Cause of Unexplained Lower Abdominal Pain in an Adolescent Girl.

Abstract

<h3>Background</h3> A Spigelian hernia occurs along the lateral border of the rectus abdominis muscle in the Spigelian fascia between the semilunar and semicircular lines. It represents 1–2% of all abdominal wall hernias and is usually located in the lower quadrants. Diagnosis may be difficult as symptoms are often subtle and nonspecific. A small defect may not always be felt on examination. In some cases the symptoms are even deemed to be psychiatric in origin. Persistent, pinpoint localization of pain to direct palpation is an important clue to identifying this disorder. Serious complications, such as incarceration, may occur if treatment is delayed. The purpose of this report is to heighten awareness among practitioners that Spigelian hernias may occur in adolescents and that a high index of suspicion may be necessary for diagnosis. <h3>Methods</h3> A 15 year old girl was evaluated for a several week history of pain in the right lower quadrant. The pain was desaibed as a constant dull ache which became intermittently sharp and more severe. It remained localized to a small area and did not radiate. The pain was increased with activity and relieved by rest. There was no nausea, vomiting, diarrhea, constipation, change in appetite, weight loss or relationship to meals. The patient had not missed any periods and her menses were described as normal without any relationship to the pain. There were no systemic symptoms or other complaints. She was referred for evaluation after her primary care physician was unable to establish a cause for the pain. <h3>Results</h3> Upon consultation. her physical examination was entirely unremarkable other than the presence of persistent, pinpoint pain to fingertip palpation in the right lower quadrant. This reproduced the pain the patient was experiencing. There also appeared to be a small underlying defect in the same area. These findings raised the possibility of a Spigelian hernia. Sonograms of the abdominal wall and pelvis were negative. The pain was found to completely disappear after injection with a local anesthetic, but not with placebo. An anatomic abnormality in the abdominal wall was strongly suspected in view of the clinical findings. Surgical exploration revealed a 6mm Spigelian hernia which was repaired and the patient became entirely asymptomatic. <h3>Conclusion</h3> This case illustrates the importance of including Spigelian hernias in the differential diagnosis of unexplained lower abdominal pain in adolescents. Signs and symptoms are often subtle which may pose a dilemma for the practitioner and lead to unnecessary tests or referrals. Persistent, reproducible. pinpoint pain to fingertip palpation is an important clue to diagnosis. Failure to recognize a Spigelian hernia not only prolongs pain, but may also result in potentially serious adverse sequelae. Clinicians who care for adolescents must be aware that such defects may occur in this age group so that the diagnosis is established as soon as possible and treattnent initiated in a timely manner.