AJR 2000; 174:1538
© American Roentgen Ray Society
Trauma Cases from the Medical Center of Delaware |
Intestinal Perforation from Blunt Trauma to an Inguinal Hernia
Raul N. Uppot1,
Vinay K. Gheyi,
Rahul Gupta and
Sharon W. Gould
1
All authors: Department of Radiology, Medical Center of Delaware, Christiana
Care Health System, 4755 Ogletown-Stanton Rd., Newark, DE 19718.
Received December 1, 1999;
accepted after revision January 24, 2000.
Address correspondence to R. N. Uppot.
Introduction
A 47-year-old man with a 6-month history of an inguinal hernia presented to
the emergency department. The patient was attempting to kick-start a
motorcycle when it lurched forward into the bumper of a parked car. The
motorcycle handlebar struck his left lower abdomen and left inguinal region.
Four hours after the accident, the patient presented with worsening severe
abdominal pain. Examination of the patient in the emergency department
revealed tenderness of the inguinal hernia and diffuse abdominal tenderness.
CT detected free intraperitoneal air (Fig.
1A), bowel wall enhancement
(Fig. 1B), free air within the
left inguinal hernia sac (Fig.
1C), and free fluid in the scrotum
(Fig. 1D). An exploratory
laparotomy revealed a 23-cm segment of perforated sigmoid colon lying within
the left inguinal hernia sac. The patient underwent sigmoid colon resection
and Hartmann's procedure.
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Fig. 1B. —Axial CT scans of 47-year-old man with trauma to left inguinal
hernia. Scan lower in pelvis than A shows bowel wall thickening and
enhancement (arrow), compatible with intestinal injury.
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Discussion
Twenty-five percent of men and 2% of women develop inguinal hernias in
their lifetime [1]. The more
commonly reported complications of unrepaired inguinal hernias include
incarceration and strangulation of intestinal structures. Overall, 5% of
patients with blunt abdominal trauma have intestinal and mesenteric injury
[2]. Intestinal perforation in
patients with hernias has been reported from blunt trauma to the abdomen
[3,4]
and more rarely from blunt trauma directly to the inguinal hernia
[5].
In patients with hernias, intestinal perforation from blunt abdominal
trauma has been reported to occur more commonly in men and particularly in men
older than 45 years [4].
Intestinal perforation has occurred more frequently in patients with right
inguinal hernias and has also been reported in patients with femoral,
perineal, and incisional hernias
[4]. Perforation results from
deceleration and compression forces
[2]. Deceleration injuries are
a result of stretching and linear tearing between fixed and movable objects.
Intestinal loops near points of fixation such as Treitz's ligament, the
ileocecal valve, and the phrenocolic ligament are susceptible to such
injuries. Compression forces increase the intraluminal pressure of the bowels
and cause rupture. In blunt abdominal trauma, increased intraabdominal
pressure can increase intraluminal pressure, and intestinal loops overlying
the hernia aperture can blow out over the aperture
[4]. Intestinal loops trapped
inside a hernia are also susceptible to perforation. The adult inguinal canal
is approximately 4 cm long and is bounded anteriorly by the external oblique
aponeurosis muscle, posteriorly by the transversalis fascia and the
aponeurosis of the transversus abdominis muscle, superiorly by the internal
abdominal oblique and transversus abdominis muscles, and inferiorly by the
inguinal and lacunar ligaments.
In 1995, Reynolds [5]
explained how direct trauma to an inguinal hernia compressed the incoming and
outgoing loops of bowel; then additional pressure applied to the sealed loop
generated enough intraluminal pressure to cause a perforation. He showed how
direct trauma to an inguinal hernia can generate spikes of pressure greater
than 300 mm Hg, more than the 150-260 mm Hg needed to rupture intestinal
loops.
Evaluating suspected intestinal perforation from blunt trauma requires a
systemic approach. Initial upright chest or left lateral decubitus radiographs
can reveal as little as 1-2 ml of free intraperitoneal air. Supine abdominal
radiographs may show air outlining the serosa of the intestinal loops (double
wall or Rigler sign) and air outlining the falciform ligament. CT of blunt
abdominal trauma should include the administration of water-soluble oral and
IV contrast material. If colonic perforation is suspected, rectal contrast
material may be used. On CT, bowel perforation is suspected with the presence
of free intraperitoneal air or free fluid. Specific CT findings of intestinal
injury include extravasated oral contrast material, bowel wall thickening,
bowel wall enhancement, bowel wall discontinuity, and mesenteric hematoma
[2].
External forces that may seem too trivial to cause intraperitoneal visceral
organ injury in the setting of blunt trauma can cause significant injury when
applied to a patient with a hernia. Whether the intestinal loops lie across
the hernia defect or are trapped within the hernia sac, careful evaluation for
intestinal injury is required in patients sustaining blunt trauma.
References
-
Eubanks S. Hernias. In: Sabiston DC, ed. Sabiston
textbook of surgery. Philadelphia: Saunders,
1997: 1215-1233
-
Novelline RA, Rhea JT, Bell T. Helical CT of abdominal trauma.
Radiol Clin North Am
1999;37:591
-612[Medline]
-
Vyas BK, Saha SM, Chokshi RM. The association of inguinal hernia
with traumatic perforation of the intestine. J Indian Med
Assoc 1996;46:156
-157
-
O'Leary JP, MacGregor AMC. Rupture of the intestine in patients
with hernia. South Med J
1975;68:463
-467[Medline]
-
Reynolds RD. Intestinal perforation from trauma to an inguinal
hernia. Arch Fam Med
1995;4:972
-974[Abstract]
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Introduction
Discussion
