Case Report Page 1 of 2 Compe ng interests: none declared. Conflict of Interests: none declared. All authors contributed to the concep on, design, and prepara on of the manuscript, as well as read and approved the final manuscript. All authors abide by the Associa on for Medical Ethics (AME) ethical rules of disclosure. Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY) FĔė ĈĎęĆęĎĔē ĕĚėĕĔĘĊĘ: Antoniou Z, Volakaki E, Giannakos E, Kostopoulos DC, Chalazonitis A. Intestinal obstruction due to an obturator hernia: a case report with a review of the literature. OA Case Reports 2013 Jan 31;2(1):5. Intestinal obstruction due to an obturator hernia: a case report with a review of the literature Z Antoniou 1 *, E Volakaki 1 , E Giannakos 1 , DC Kostopoulos 2 , A Chalazonitis 1 Abstract Introduction Obturator hernia is a rare abdominal hernia and a diagnostic challenge. It is a significant cause of intestinal obstru- ction in thin, elderly women. Delayed diagnosis and surgical intervention c- auses its high morbidity and mortalit- y. Computed tomography is a valuable tool for preoperative diagnosis. This r- eport presents an Intestinal obstructi- on due to an obturator hernia. Case report This report presents the case of an 84- year-old female patient with a small bowel obstruction caused due to an obturator hernia. Conclusion A computed tomography scan is valu- able to establish preoperative diagno- sis. Early diagnosis and surgical treat- ment contribute greatly to reduce the morbidity and mortality rate. Introduction Obturator hernia was first described by Arnaud de Ronsil. It is considered to be rare and accounts for 0.05%– 0.4% off all hernias 1 and 0.2%–1.6% of all cases of mechanical intestinal obstruction 2 . It is more common in thin, elderly females and has a high mortality rate between 13% and 40% 3 . Rapid evaluation and early surgical intervention can reduce morbidity and mortality. A computed tomography (CT) scan of the pelvis and upper thigh is the best imaging tool in obturator hernia. This report discusses an intestinal obstruction caused in a patient due to an obturator hernia. Case report An 84-year-old female was admitted to our hospital with colicky abdom- inal pain and repeated episodes of vomiting. Pain was localised over the periumbical area and radiated along the medial side of the thigh. On physical examination, the patient’s vital signs were stable, her abdomen was distended centrally and abdom- inal tenderness was present with no evidence of peritonitis or free fluid. There were hyperactive bowel sounds. No abnormal signs were found on rectal and vaginal exami- nations. Biochemical parameters were within normal limits. Plain abdominal radiography revealed multiple distended bowel loops. A CT scan and reconstruction of the acquired images in coronal and axial planes was performed to deter- mine the cause of bowel obstruction (Figure 1). The CT scan demon- strated dilated fluid-filled loops of small bowel up to a herniated loop of small bowel, through the obturator canal (Figure 2). Small bowel loop was noted between the pectineus and the left external obturator muscle (Figure 3). Obturator hernia was diagnosed and emergency surgical treatment was arranged. Discussion Obturator hernia proceeds through the obturator foramen situated bilat- erally in the anterolateral pelvic wall, interiorly to the acetabulum. The obturator artery, vein and nerve pass through this tunnel protected by extraperitoneal connective tissue and fat 4,5 . Typically, obturator hernias occur in elderly women or patients with chronically raised intra-abdominal * Corresponding author Email: [email protected] 1 Radiology Department, Alexandra General Hospital, Athens, Greece 2 Medical School, University of Athens, Greece Surgery Figure 1: CT scout demonstrating multiple dilated small bowel loops. Figure 2: CT scan demonstrating mechanical small bowel obstruction: multiple dilated fluid-filled small bowel loops (red arrow) and normal- sized, small bowel loops distal to the hernia (green arrow). Figure 3: CT scan demonstrating a small bowel loop between the pectineus and the left external obturator muscle (red arrow).
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Case Report
Page 1 of 2
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Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY)
F : Antoniou Z, Volakaki E, Giannakos E, Kostopoulos DC, Chalazonitis A. Intestinal obstruction due to an obturator hernia: a case report with a review of the literature. OA Case Reports 2013 Jan 31;2(1):5.
Intestinal obstruction due to an obturator hernia:a case report with a review of the literature
Z Antoniou1*, E Volakaki1, E Giannakos1, DC Kostopoulos2, A Chalazonitis1
AbstractIntroductionObturator hernia is a rare abdominal hernia and a diagnostic challenge. It is a significant cause of intestinal obstru-ction in thin, elderly women. Delayed diagnosis and surgical intervention c-auses its high morbidity and mortalit-y. Computed tomography is a valuable tool for preoperative diagnosis. This r-eport presents an Intestinal obstructi-on due to an obturator hernia.Case reportThis report presents the case of an 84-year-old female patient with a small bowel obstruction caused due to an obturator hernia.ConclusionA computed tomography scan is valu-able to establish preoperative diagno-sis. Early diagnosis and surgical treat-ment contribute greatly to reduce the morbidity and mortality rate.
IntroductionObturator hernia was first described by Arnaud de Ronsil. It is considered to be rare and accounts for 0.05%–0.4% off all hernias1 and 0.2%–1.6% of all cases of mechanical intestinal obstruction2. It is more common in thin, elderly females and has a high mortality rate between 13% and 40%3. Rapid evaluation and early surgical intervention can reduce morbidity and mortality. A computed tomography (CT) scan of the pelvis and upper thigh is the best imaging tool in obturator hernia. This report discusses an intestinal
obstruction caused in a patient due to an obturator hernia.
Case report An 84-year-old female was admitted to our hospital with colicky abdom-inal pain and repeated episodes of vomiting. Pain was localised over the periumbical area and radiated along the medial side of the thigh. On physical examination, the patient’s vital signs were stable, her abdomen was distended centrally and abdom-inal tenderness was present with no evidence of peritonitis or free fluid. There were hyperactive bowel sounds. No abnormal signs were found on rectal and vaginal exami-nations. Biochemical parameters were within normal limits. Plain abdominal radiography revealed multiple distended bowel loops. A CT scan and reconstruction of the acquired images in coronal and axial planes was performed to deter-mine the cause of bowel obstruction (Figure 1). The CT scan demon-strated dilated fluid-filled loops of small bowel up to a herniated loop of small bowel, through the obturator canal (Figure 2). Small bowel loop was noted between the pectineus and the left external obturator muscle (Figure 3). Obturator hernia was diagnosed and emergency surgical treatment was arranged.
DiscussionObturator hernia proceeds through the obturator foramen situated bilat-erally in the anterolateral pelvic wall, interiorly to the acetabulum. The obturator artery, vein and nerve pass through this tunnel protected by extraperitoneal connective tissue and fat4,5. Typically, obturator hernias occur in elderly women or patients with chronically raised intra- abdominal
* Corresponding authorEmail: [email protected] Radiology Department, Alexandra General
Hospital, Athens, Greece2 Medical School, University of Athens, Greece
Surg
ery
Figure 1: CT scout demonstrating multiple dilated small bowel loops.
Figure 2: CT scan demonstrating mechanical small bowel obstruction: multiple dilated fluid-filled small bowel loops (red arrow) and normal-sized, small bowel loops distal to the hernia (green arrow).
Figure 3: CT scan demonstrating a small bowel loop between the pectineus and the left external obturator muscle (red arrow).
Case Report
Page 2 of 2
Com
pe n
g in
tere
sts:
non
e de
clar
ed. C
onfl i
ct o
f int
eres
ts: n
one
decl
ared
.A
ll au
thor
s co
ntrib
uted
to th
e co
ncep
on,
des
ign,
and
pre
para
on
of th
e m
anus
crip
t, a
s w
ell a
s re
ad a
nd a
ppro
ved
the fi n
al m
anus
crip
t.A
ll au
thor
s ab
ide
by th
e A
ssoc
ia o
n fo
r Med
ical
Eth
ics
(AM
E) e
thic
al ru
les
of d
iscl
osur
e.
Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY)
F : Antoniou Z, Volakaki E, Giannakos E, Kostopoulos DC, Chalazonitis A. Intestinal obstruction due to an obturator hernia: a case report with a review of the literature. OA Case Reports 2013 Jan 31;2(1):5.
pressure. The female predomi-nance of these hernias is the result of pregnancy, which leads to relaxa-tion of the pelvic peritoneum and a wider and more horizontal obtu-rator canal5. In general, obturator hernias are asymptomatic unless the hernia sac compresses the obtu-rator nerve and produces the pathog-nomonic Howship–Romberg sign, which includes pain with or without paresthaesia localised down the anteromedial thigh to the knee upon movement of the hip or thigh.
The Howship–Romberg sign is positive in 15%–50% of cases6,7. The Hannington–Kiff sign, a clinical sign in which there is an absent adductor reflux in the thigh, is more specific but less known6,8. Other symptoms include acute or intermittent small bowel obstruction with high risk of strangulation, weight loss and rarely a palpable mass6,7. Various imaging examinations such as ultrasonog-raphy, herniography and CT scan have been applied to establish the diagnosis. The best imaging tool is CT which has superior sensitivity and accuracy6,7. Bowel herniating through the obturator foramen and lying between the pectineus and obturator muscles is a key finding on CT and determines the diagnosis7. CT also differentiates the obtu-rator hernia from other abdominal masses, such as tumours , haema-tomas and abscesses. Thin, refor-matted images of 2.5 mm or less may
better delineate the size and shape of the hernia sac and associated complications3. Intravenous admin-istration of contrast medium helps check the vascular supply of the bowel wall to detect complications such as ischemia. Dilation of small bowel proximal to the hernia is a sign of obstructed hernia. The intra- abdominal approach through a low midline incision is most commonly used as it can establish the diagnosis, avoid the obturator vessels, expose the obturator ring and facilitate bowel resection if necessary9. Retro-public, preperitoneal, groin or lapa-roscopic approaches may be used if the diagnosis is made preoperatively.
ConclusionObturator hernia remains an impor-tant diagnosis to consider in elderly patients with intestinal obstruction. CT scan is valuable to establish preop-erative diagnosis. Early diagnosis and surgical treatment contribute greatly to reduce the morbidity and mortality rate.
Abbreviations listCT, computed tomography.
ConsentWritten informed consent was obtained from the patient for publi-cation of this case report and accom-panying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
References1. Skandalakis LJ, Skandalakis PN, Gray SW, Skandalakis JE. Obturator hernia. In: Nyhus LM, Condon RE, editors. Hernia. 4th ed. PhiIadelphia: J.B. Lippincott Co; 1995.p425–39.2. Thanapaisan C, Thanapaisal C. Sixty-onecases of obturator hernia in Chiangrai Regional Hospital: retrospective study. J Med Assoc Thai. 2006 Dec;89(12):2081–5.3. Aguirre D, Santosa A, Casola G, Sirlin C.Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 2005 Nov–Dec;25(6):1501–20.4. Whiteside JL, Walters MD. Anatomy of the obturator region: relations to a trans-obturator sling. Int Urogynecol J Pelvic Floor Dysfunct. 2004 Jul–Aug;15(4):223–6.5. Hsu CH, Wang CC, Jeng LB, Chen MF. Obturator hernia: a report of eight cases. Am Surg. 1993 Nov;59(11):709–11.6. Cai X, Song X, Cai X. Strangulated intes-tinal obstruction secondary to a typical obturator hernia: a case report with literature review. Int J Med Sci. 2012 Mar;9(3):213–5.7. De Clercq L, Coenegrachts K, Feryn T,Van Couter A, Vandevoorde R, Verstraete K, et al. An elderly woman with obstructed obturator hernia: a less common variety of external abdominal hernia. JBR-BTR. 2010 Nov–Dec;93(6):302–4.8. Hannington-Kiff JG. Absent thigh adductor reflex in obturator hernia. Lancet. 1980 Jan;1(8161):180.9. Nakayama T, Kobayashi S, Shiraishi K, Nishiumi T, Mori S, Isobe K, et al. Diag-nosis and treatment of obturator hernia. Keio J Med. 2002 Sep;51(3):129–32.
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