A 70-Year-Old Man With Deteriorating Mental Status and Pain

Gamal A. Bebars, MD, FRCS; Evelyn P. Bebars, MD, FPCR

Disclosures

October 23, 2018

Discussion

This patient was in septic shock. The patient's supine plain chest x-ray excluded pulmonary septic pathology; however, it raised the suspicion of a diaphragmatic hernia in the left hemithorax. This possibility was excluded by the CT scan, which showed an intact left hemidiaphragm. Abdominal x-ray and CT scanning both excluded the presence of sigmoid volvulus. Contrast-enhanced CT scanning further revealed intact bowel circulation in both the arterial and venous phases, eliminating the possibility of mesenteric occlusion as the cause of the abdominal signs.

The presence or absence of free air in the peritoneal cavity could not be ascertained on the plain film because of the gross bowel distention. This was also the reason abdominal ultrasonography was not used, as the excessive distention would have reduced its diagnostic efficacy. Although the CT scan of the abdomen could not visualize the vermiform appendix in the right lower quadrant, it clearly detected a small right inguinal hernia with an air-filled space among the hernia's contents.

This hernia could not be identified during the physical examination because of the small size, inability to elicit a cough impulse, the use of mechanical ventilation, and the patient's obesity. Preoperatively, the etiology of the patient's sepsis could not be confirmed, but the working diagnosis was that of a strangulated inguinal hernia resulting in generalized peritonitis and ileus. The diagnosis of a complicated Amyand hernia associated with the perforation of an inflamed appendix was made only following laparotomy, as is the case in almost all the reported case series.[1,2]

An Amyand hernia is an inguinal hernia that contains the vermiform appendix within its hernial sac; it is named after English surgeon, Claudius Amyand. Only approximately 0.13% of cases of Amyand hernia cases are associated with appendicitis hernia, whereas a noninflamed appendix is found in about 1% of all hernia repairs. The differential diagnoses for Amyand hernia should include strangulated hernia, strangulated omentocele, Richter hernia, testicular tumor with hemorrhage, acute hydrocele, and inguinal adenitis.

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