Case of the Month Resolve

Medical Student Elective

Case of the Month
March
Submitted by: Katherine Brown, MS4 Columbia P&S

What is the most likely diagnosis for this patient?
Incarcerated hernia with SBO

To the OR or not?


Course:
The pt was admitted to General Surgery. Her hernia was reduced on hospital day one. Her pain improved after manual reduction and her diet was advanced. She was discharged on hospital day 2 with instructions to follow-up with her primary care doctor and a general surgeon upon returning home.


Discussion:
The diagnosis of SBO is often made by upright or lateral decubitus abdominal xray. However, CT of the abdomen and pelvis is considered the gold standard and is often needed after abdominal films to make the diagnosis. Ultrasound can also be used in evaluation of a patient with SBO.


The use of bedside ultrasound in the diagnosis of SBO:

Ultrasound can be done at the bedside, is fast, cheap, can be utilized in low resource settings and has no radiation. The diagnosis of SBO is supported by ultrasound when dilated loops of bowel greater than 25mm are found.


Dilated loops of bowel on ultrasound:



Pictures from Jang et al 2010)


When compared to Xray, ultrasound has better sensitivity and specificity in diagnosing SBO. Jang and colleagues compared xray and ultrasound in the diagnosis of suspected SBO in the emergency room setting.

  • 76 patients had abdominal US before abdominal xray and CT
  • No indeterminate US studies, no indeterminate CT, 27 non-diagnostic xrays
  • Ultrasound:
    • Dilated bowel: Sensitivity 91%, Specificity 84%
    • Decreased bowel peristalsis: Sensitivity 27%, Specificity 98%
  • Xray: Sensitivity 46.2%, Specificity 66.7% (when diagnostic)


These findings have been supported by other studies as well. Schmutz and colleagues found that bedside ultrasound was 95% specific and 82.1% specific in diagnosing bedside ultrasound.


Incarcerated hernias account for about 10% of cases of SBO. In incarcerated hernias, the bowel contents are stuck in the hernia sack. On the other hand, in strangulated hernias, the tissue within the hernia have a compromised blood supply. Incarcerated hernias can be managed with manual reduction, but strangulated hernias must be managed surgically.


In one case report, the diagnosis of incarcerated vs. strangulated hernia was made by bedside ultrasound. Bedside ultrasound was first used to confirm the diagnosis of a hernia and interrogation with Doppler allowed for the confirmation of blood flow. The diagnosis of incarcerated hernia was made and manual reduction of the hernia was undergone at the bedside.


References:
Jang TB, Schindler D, and Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J. 2010.

Kulstad E, Pittman L, Konicki PJ. Ultrasound in the diagnosis of incarcerated hernia. The Internet Journal of Emergency Medicine. 2003; 1(1).

Schmutz GR, Benko A, Fournier L, Peron JM, Morel E, Chiche L. Small bowel obstruction: role and contribution of ulrasonography. Eur Radiol. 1997; 7(7):1054-8.

http://www.ultrasoundpodcast.com/2012/10/episode-36-small-bowel-obstruction



Every month during director’s rounds, our students present interesting and educational cases. This is a synopsis of the case voted to be the best by the students and directors at the end of director’s rounds along with an interesting image.



Medical Student Program Directors

Jamie Edelstein, MD and Chen He, MD
slredmedstuds@gmail.com

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