The Case Files

Abstract

An 81-year-old man presented to the emergency department complaining of acute onset abdominal pain, vomiting for one day, and subjective fever and chills. The patient had had non-bloody bowel movements, and was able to pass flatus. The patient said the pain started suddenly the day before, and that it was accompanied by two episodes of bilious non-bloody vomiting. The patient had a surgical history, including bilateral inguinal hernia repair in 1974, a repeat left inguinal hernia repair in 1996, and lip cancer surgery in 2009. His vitals were normal except for a rectal temperature of 101.6°F. Physical examination was significant for abdominal distension, abdominal tenderness, guarding over the right lower quadrant and inguinal region, and hyperactive bowel sounds. Routine blood work was normal, with the exception of an elevated white blood count of 14.6, lactate of 4.4, BUN of 12, and creatinine of 0.6. Urinalysis showed a slight increase of ketones. Radiological imaging was obtained in the form of an abdominal CT that showed a bowel loop extending through the abdominal wall. Purulent fluid was present once we entered the peritoneal cavity during an exploratory laparotomy. Investigation of the right lower quadrant identified a portion of antimesenteric wall of the small bowel located in the right inguinal hernia sac. Necrotic regions of the small bowel with perforations were noted. A palpable, movable mass was found within the necrotic regions. The hernia was closed as the area of diseased small bowel was excised.Figure: An apricot in necrotic loop of bowel.Discovered within the excised portion of the bowel was a phytobezoar identified as an apricot that measured approximately 4 cm in length. Postoperatively and upon further questioning, the patient said he stopped wearing his dentures after the lip surgery and was placed on a puree diet. He had been eating apricots while visiting his brother the day before the pain started.Figure: Affected loop of bowel with areas of necrotic tissue.Figure: Expectorated apricot from necrotic loop of bowel.Richter first described hernias where a portion of the bowel was strangulated in 1785. (Ann Surg 2000;232[5]:710.) Richter's hernias can progress to gangrene faster when compared with other types of hernias. They most commonly affect the ileum, but any part of the bowel can be affected. (Nyhus and Condon's Hernia. Philadelphia: Lippincott, 1989; 305.) The lumen of the hernia remains free of preventing obstruction. With no intestinal obstruction between onset, symptoms, and identification, there is more time for bowel necrosis to set in and progress. Richter's hernias are divided into four groups. (Ann Surg 2000;232[5]:710.) The obstructive group has symptoms of intestinal obstruction that lead to early diagnosis. The danger group is where symptoms are vague and delay identification and treatment, which increases mortality. The post-necrotic group is where perforation leads to formation of a fistula. The fourth is called the unlucky perforation group, in which a post-necrotic abscess leads to sepsis or peritonitis. (Ann Surg 2000;232[5]:710.) Immediate intervention is required when a Richtner's hernia is suspected. The patient's symptoms, physical examination, lab results, and CT scan in this case indicated that immediate surgical intervention was required. The patient recovered, and was discharged three days later.