A case of obturator hernia with overlooked Howship-Romberg sign and treated as sciatica

We report a case of a patient with incarcerated obturator hernia who presented with right thigh pain. An 88-year-old woman who had experienced right thigh pain for the previous 3 years was given a diagnosis of sciatica at the orthopedic department. In July 2009, she was hospitalized with the chief complaint of appetite loss. The day after admission she experienced increased right thigh pain and lower abdominal pain. Abdominal ultrasonography revealed a keyboard sign. Based on this finding, we diagnosed an ileus, which was alleviated by the insertion of an ileus tube. However, after the removal of the ileus tube, her right thigh pain recurred. Therefore, a diagnosis of hernia was considered. Contrast-enhanced computed tomography revealed an incarcerated bowel in the region between the pectineus muscle and muscle obturator. Laparotomy showed that the ileal part located about 15 cm from the terminal ileum was incarcerated in the right foramen obturatum; therefore, ileal resection and end-to-end anastomosis were performed. After the operation, her intestinal obstruction symptoms and right pain disappeared. If right pain and ileus symptoms of unknown cause occur in elderly persons, obturator hernia should be considered.     

Left-sided omental torsion with inguinal hernia

We report a case of surgically proved left-sided torsionof the greater omentum that caused secondary byuntreated inguinal hernia.Case A 36-year-old manpresented to our hospital with abdominal pain.Hehad been diagnosed with a left inguinal hernia,but hehad not received any treatments.Contrast-enhancedcomputed tomography(CT)of the abdomen showeda large fat density mass below the Sigmoid colon andleft inguinal hernia with incarcerated fat.Exploratorylaparotomy revealed torsion of the greater omentumwith small bloody ascites.The greater omentum wastwisted into one and a half circles and entered into a leftinguinal hernia.An omentectomy with a repair of leftinguinal hernia was performed.A resected omentum wassubmitted for pathological examination,which showedhemorrhagic infarction.Omental torsion is a rare causeof acute abdominal pain but should be included in thedifferential diagnoses of acute abdomen,especially inpatients with untreated inguinal hernia.     

Large-bowel obstruction as a late sequela of retrosternal diaphragmatic hernia

A 37-year-old man with a past history of a fall from height 16 years previously was admitted with acute abdomen. Investigations revealed intestinal obstruction caused by a diaphragmatic hernia. He had an incarcerated omentum and Richter's hernia of the transverse colon secondary to left diaphragmatic hernia leading to colonic ileus. Following resection of the strangulated omentum and reduction of the colon intraabdominally, a surgical repair of the hernia was performed using an abdominal and transthoracic approach. The relatively rare late complication of a left-sided enterothorax with ileus makes this a remarkable case and underlines the need for early surgery to avoid late complications.     

A case of left-sided Morgagni hernia complicating incarcerated small bowel hernia]

Morgagni hernia is an uncommon presentation representing about 3% in incidence and usually located in the right-sided anterior diaphragm. We experienced a case of Morgagni hernia in a seventy four-year-old male who was admitted complaining of intermittent abdominal pain. The diagnosis was made initially by chest and abdominal radiography, and an incarcerated Morgagni hernia was finally diagnosed with abdominal CT scans. Emergent laparotomy was performed. Morgagni foramen was located on the left-sided anterior diaphragm and Morgagni hernia which contained greater omentum and strangulated small intestine was gently reducted. Morgagni foramen measuring 4 x 5 cm was repaired with a Gortex mesh. We reported the experience of left-sided Morgagni hernia complicating incarcerated small bowel hernia in an old male patient.     

LAPAROSCOPIC COMPOSITE‐MESH REPAIR OF AN ADULT MORGAGNI HERNIA

Congenital Morgagni hernia is a rare clinical condition. We present a 72‐year‐old man with epigastric discomfort and hematemesis who was diagnosed with hernia of Morgagni with an incarceration of the stomach and colon. The patient was treated electively by laparoscopic composite‐mesh repair without excising the hernial sac or approximating the edges of the defect, which was 10 × 6 cm in diameter. He was discharged on the seventh postoperative day without any complications. At a 1‐year follow‐up examination he had no recurrence nor clinical symptoms, although the large hernial sac contained fluid. Laparoscopic composite‐mesh repair is a less‐invasive and tension‐free method for Morgagni hernia that results in an excellent clinical outcome.     

Rare Case of Internal Hernia with a New Type of Hepatodiaphragmatic Interposition of the Stomach and Colon

We report a new type of retroperitoneal internal hernia with hepatodiaphragmatic interposition of the stomach and colon. The hernia neck was formed in the lesser omentum, and the hernia sac consisted of the lesser omentum and retroperitoneum. The herniated organs (the stomach and colon) were incarcerated in the right extraperitoneal subphrenic space from the left dorsal side of the sulcus vena cava. This is the first reported case of this type.     

Parahiatal hernia with gastric obstruction in a child.

Parahiatal hernia refers to herniation of abdominal viscera into the chest adjacent to an intact hiatus. Spontaneously occurring parahiatal herniae are extremely rare. We report a 4-year-old boy who presented with intermittent vomiting and had such a hernia, where the herniated stomach had undergone partial volvulus. He was symptom-free after surgical repair.     

Strangulated small bowel hernia through the port site： A case report

Port site hernia develops through a fascial or peritoneal layer that was inadequate or not repaired. It is a rare complication of laparoscopic surgery which may lead to serious problems. Here, we present a 77-year-old female, diagnosed with a small bowel hernia through a 10-mm port site. We had performed ten cases of laparoscopy-assisted distal gastrectomy before this case. The patient complained of left lower abdominal pain with a palpable mass. Abdominal CT showed an incarcerated small bowel hernia and the patient underwent segmental resection of the strangulated small bowel through a minimally extended port site incision.     

A pancreatico-bronchial fistula with right hydropneumothorax

A 39-year-old heavy drinker was admitted to Saga Medical School Hospital on February 21th, 1987. He had suffered from dyspnea, chest pain and lumbago three weeks prior to admission. His chest X-ray showed right hydropneumothorax and right lower lobe atelectasis and his CT scan showed a cystic lesion in the mediastinum. His laboratory data showed a high level of amylase in serum, urine and pleural effusion. A fistula connecting the pancreas to right pleural cavity was demonstrated by endoscopic retrograde cholangiopancreatography (ERCP). In addition, bronchoscopy showed complete obstruction of the right lower bronchus (B7). These bronchoscopic findings and hydropneumothorax on his chest X-ray suggested the leakage of pancreas juice through the pancreatico-pleural fistula injured the lung tissue directly and produced a bronchopleural fistula. In this case, hyperalimentation and drug therapy using protease inhibitor resulted in successful closure of the fistula and reexpansion of the collapsed lung.     

Small bowel obstruction from internal hernia as a complication of colonoscopy.

After colonoscopy with polypectomy, a patient developed a surgically acute abdomen. Although abdominal radiology did not show free air, a presumptive diagnosis of bowel perforation was made and laparotomy performed. At the time of surgery the colon was normal, and there was no peritoneal contamination. A loop of ileum was discovered incarcerated into an internal paracecal hernia. The bowel was freed, and the operation was completed without need for resection. Several cases of incarcerated inguinal hernia resulting from endoscopy are described in the medical literature; this is the first reported case of an incarcerated internal hernia as a complication of colonoscopy.     

Obturator Hernia: A Diagnostic Challenge of Small-Bowel Obstruction

Obturator hernia is relatively rare and is a diagnostic challenge in the emergency department because the hernia mass is usually concealed beneath the pectineus muscle. We report the case of a 91-year-old emaciated woman with an incarcerated obturator hernia. The hernia was discovered early in the emergency department by computed tomography and was reduced by emergency laparotomy. The Howship-Romberg sign and pain from the ipsilateral thigh to the knee are important clinical manifestations raising suspicion of obturator hernia, but these did not occur in our patient. One of the clinical clues in our patient was small-bowel obstruction of unknown origin, diagnosed by computed tomography. We emphasize that emergency physicians should keep a high index of clinical suspicion for obturator hernia when encountering small-bowel obstruction in emaciated elderly women. Although we cannot shorten the time from onset of symptoms to hospital admission, we can make rapid evaluation and surgical intervention to reduce the morbidity and mortality of obturator hernia.     

Terminal ileum gangrene secondary to a type Ⅳ paraesophageal hernia

Type Ⅳ paraesophageal hernia(PEH) is very rare, and is characterized by the intrathoracic herniation of the abdominal viscera other than the stomach into the chest. We describe a 78-year-old woman who presented at our emergency department because of epigastric pain that she had experienced over the past 24 h. On the day after admission, her pain became severe and was accompanied by right chest pain and dyspnea. Chest radiography revealed an intrathoracic intestinal gas bubble occupying the right lower lung field. Emergency explorative laparotomy identified a type Ⅳ PEH with herniation of only the terminal ileum through a hiatal defect into the right thoracic cavity. In this report, we also present a review of similar cases in the literature published between 1980 and 2015 in Pub Med. There were four published cases of small bowel herniation into the thoracic cavity during this period. Our patient represents a rare case of an individual diagnosed with type Ⅳ PEH with incarceration of only the terminal ileum.     

Intrapleural perforation of peptic ulcer in association with diaphragmatic hernia

Two patients with perforation of intrathoracic peptic ulcer in association with paraoesophageal hiatus hernia are described. This unusual complication of hiatus hernia should be considered in the differential diagnosis of patients presenting with spontaneous hydropneumothorax.     

“Acute coronary syndrome” and heart failure caused by a large hiatal hernia

Upside down stomach (UDS) as a severe form of hiatal hernia has various clinical scenarios. Patients could be asymptomatic or present with haemodynamic collapse due to mechanical compression of the mediastinum.We herein present a case of 71-year-old woman referred to our clinic due to acute coronary syndrome with acute onset of heart failure, which was treated accordingly. Throughout the diagnostic and therapeutic process, a diagnosis of an incarcerated UDS was established as a trigger of her symptoms. An acute surgery was performed. Despite complications in the post-op period the patient recovered successfully and was referred to a rehabilitation facility for further therapy.     

Incarcerated Spieghel-Hernie mimicking an acute exacerbation of Crohn's disease

We report on a 25-year-old woman with long-standing Crohn's disease. Upon admittance to the emergency department, the patient complained of abdominal pain with increasing intensity over the last few days. Clinical examination revealed an abdominal mass in the right lower quadrant, and blood tests showed elevated markers of inflammation. Surprisingly, abdominal ultrasound did not show the suspected complication of Crohn's disease, but rather an incarcerated abdominal wall hernia, which turned out to be a spigelian hernia upon surgical repair. This case stresses the importance of abdominal ultrasound to rule out other diagnoses in patients with chronic inflammatory bowel disease in the emergency setting before starting a potentially dangerous treatment with high-dose steroids.     

嵌顿于膀胱子宫陷凹的腹内疝致小肠梗阻1例

腹内疝是一种少见的外科急腹症,最常表现为小肠肠管进入正常或异常孔隙而导致的肠梗阻.由于解剖结构的因素,腹内疝有多种类型,但嵌顿于膀胱子宫陷凹的腹内疝迄今未见报道.本文报道嵌顿于膀胱子宫陷凹的腹内疝致小肠梗阻1例.患者女性,35岁,以"下腹突发剧烈绞痛2h"入院.腹部彩超和CT显示小肠肠管扩张,肠管内积液.扩张肠管堆积位于子宫前方与膀胱后方.急诊剖腹探查发现,距回盲瓣40cm处见一约50cm小肠经由膀胱子宫陷凹处疝入,因无肠管血运异常,仅行肠粘连松解术治疗.本病例提示,超声和CT不仅有助于发现小肠梗阻的病因,更有助于各型腹内疝的诊断.     

Primary squamous cell carcinoma of the stomach: a case report and review of the literature

Primary squamous cell carcinoma of the stomach is extremely rare. To date, only 80 cases have been reported. A 65-year-old man with complaints of epigastric pain and cachexia for the past year is presented. He had a tumour with infiltration of the corpus and antrum of the stomach. The tumour was unresectable, and the patient died within 3 months.     

Cases from the Osler Medical Service at Johns Hopkins University. Pseudoachalasia due to esophageal adenocarcinoma

Presenting features

A 69-year-old man presented with nausea and vomiting. He was in good health until 2 years before presentation, when he first noted occasional difficulty eating solid foods. He could chew food without difficulty, but sometimes he had the sensation that the food was lodged in his chest. This sensation would persist for several hours; occasionally, he would need to induce emesis for relief.These episodes of chest discomfort became more frequent over time. Two weeks before presentation, he had to induce emesis after every meal and began having difficulty ingesting both liquids and solids. On the day of his presentation, he awoke at 3:00 am feeling hungry. He drank some juice, after which he had emesis and chest pain, which led him to believe that he was having a myocardial infarction.His past medical history included hypercholesterolemia and gastroesophageal reflux disease attributed to a hiatal hernia. His only medication was simvastatin, which he stopped taking 1 month before presentation because he thought that it was con-tributing to his difficulty in swallowing. He had not smoked for more than 30 years. He previously drank one beer a day but recently stopped drinking as well. A review of systems was notable for an unintentional weight loss of 20 lbs during the past 6 months.On admission, his vital signs were normal. His chest, cardiac, and abdominal examinations were unremarkable. His electrocardiogram and laboratory tests were normal. A barium swallow (Figure 1 and Figure 2) demonstrated tapering of the distal esophagus.What is the diagnosis?     

Hiatus Hernia and Intrathoracic Migration of Esophagogastric Junction in Gastroesophageal Reflux Disease

The prevalence and clinical presentation of reducible and irreducible hiatus hernia were investigated within a gastro-esophageal reflux disease patient population. Reflux symptoms and esophagitis data were collected on 791 patients. The barium swallow was used to assess the esophagogastric junction. Clinical and endoscopic findings were tested to predict radiographic findings. The esophagogastric junction was normal in 17% of patients, 53% had a sliding hiatus hernia with a reducible esophagogastric junction; in 23% it was irreducible although axial, and 8% had massive incarcerated hiatus hernia. The presence of reducible sliding hiatus hernia did not influence clinical presentation. Axial irreducibility presented with long-standing severe symptoms and esophagitis in 80% of cases. Clinical and endoscopic findings predicted axial irreducibility in 52% of cases. In conclusion, sliding hiatus hernia with an reducible esophagogastric junction does not influence the severity of gastroesophageal reflux disease. An irreducible esophagogastric junction is associated with long-standing severe gastroesophageal reflux disease. Clinical and endoscopic findings may only be indicative of axial esophagogastric junction irreducibility; thus barium swallow should be part of the work-up.     

Giant morgagni hernia causing cardiac tamponade

A 57-year-old man presented with worsening symptoms of shortness of breath and chest pain. He was found to have a giant Morgagni hernia with severe compression of his right ventricle on computed tomography scan. The hernia which contained greater omentum, small intestine and transverse colon was urgently repaired through a median sternotomy and laparotomy with a polypropylene mesh. Morgagni hernia is a type of congenital diaphragmatic hernia, which may not be symptomatic until adulthood. Presentation with this degree of right ventricular compression is rare.