Grace S.RozyckiMDAuthor Affiliations: Departments of Surgery (Drs Sicklick and Ahuja), Radiology (Dr Weiss), and Oncology (Dr Ahuja), The Johns Hopkins Hospital, Baltimore, Md.
A 55-year-old man with diabetes presented to the emergency department, reporting 6 days of emesis. Seven days earlier he had noticed a bulge in his right groin where he had previously undergone 2 inguinal hernia repairs. On presentation, the patient noted a history of 4 days of obstipation accompanied by bilateral lower quadrant pain.
On physical examination he was afebrile but orthostatic. His abdomen was distended with moderate tenderness to palpation in the bilateral lower quadrants. The patient had no evidence of peritoneal signs. Examination of his right groin showed a large incarcerated hernia. Rectal examination demonstrated acholic, heme-negative stool. Laboratory results were consistent with dehydration. A chest radiograph revealed no pneumoperitoneum. Abdominal radiographs were obtained (Figure 1). The patient was resuscitated and subsequently underwent exploratory laparotomy and right groin exploration without bowel preparation. The gross pathologic specimen is shown in Figure 2.
Plain radiograph of the abdomen demonstrates massively dilated loops of the small bowel, air-fluid levels in the small bowel, a cecum measuring 13 cm, and a bent inner tube sign appearing as a collection of gas that extends from the pelvis to the right upper quadrant.
Photograph of the surgical specimens demonstrating incarceration of the bowel in the right-side hernia sac.
A. Incarcerated cecum
B. Incarcerated ileum
C. Incarcerated sigmoid volvulus
D. Incarcerated cecal volvulus
Sicklick JK, Weiss CR, Ahuja N. Image of the Month—Quiz Case. Arch Surg. 2007;142(2):199. doi:10.1001/archsurg.142.2.199