CASE 735 Published on 11.12.2000
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Obstructive Ileus caused by herniation of descending colon into the rectus sheath

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

E. Kaindl, C. Gäbler, B.-N. Bloch, M. Memarsadeghi, P. Pokieser

Connected authors
Patient

84 years, female

Categories
No Area of Interest ; Imaging Technique CT
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Clinical History
An old lady presented with acute onset of abdominal pain and tenderness, paleness and decrease of hematocrit five days after a fall on her right side with a fracture of the right radius.
Imaging Findings
A 84-year old woman presented to the emergency unit after a fall on her right side with a displaced fracture of radius wich had to be reduced surgically. Five days later she showed sudden onset of abdominal pain and tenderness, paleness, the hematocrit has decreased to 26,9, the hemoglobine to 9.1, hemoccult test was positive. Abdominal plain films followed by a CT-scan were performed. Because of these imaging findings combined with the increasing ileus symptoms and hemodynamic decompensation of the patient the indication for surgical intervention was set immediately. At Laparotomy there was found a large hematoma of the left rectus sheath, caused by a rupture of the inferior epigastric artery, containing about one litre of coagulated blood and a mobile descending colon, herniated through a hole of the inner layers of the rectus sheath. The herniated parts of the colon did not show ischemic damage, so a resection had not to be performed. The colon was mobilized back and the layers of the abdominal wall closed with interrupted sutures. The old lady got well and was discharged two weeks after operation.
Discussion
Abdominal wall herniation resulting from blunt trauma is an uncommon entity with only a few cases reported. The usual pathophysiology of traumatic abdominal wall hernia may involve a considerable blunt force that is distributed over a surface area sufficiently large enough to prevent penetration but small enough to remain focal, such as a handle bar [1-2]. Rectus sheath hematoma is an uncommon condition caused by a tear in a epigastric vessel and characterized by sudden onset of severe abdominal pain and a palpable mass. A history of trauma, anticoagulant therapy and in some cases something as trivial as coughing, straining, or twisting to one side have been documented [3-5]. Rectus sheath hematoma nearly always present acutely, with abdominal pain of sudden onset, and on occasion may mimic an acute abdomen process [4]. There was no case found in literature showing these two entities occurring in combination. However, if CT-scans show a hematoma of abdominal wall, which includes parts of bowel, there has to be thought of this rare condition of herniation of bowel into a rectus sheath hematoma. In this case indication for surgical intervention had to be set immediately to prevent ischemic damage of the bowel.
Differential Diagnosis List
Rectus sheath hematoma with herniation of descending colon
Final Diagnosis
Rectus sheath hematoma with herniation of descending colon
Case information
URL: https://eurorad.org/case/735
DOI: 10.1594/EURORAD/CASE.735
ISSN: 1563-4086
Figure 1

Abdominal plain films

Abdominal plain films
Abdominal plain film - supine position. Slighthly destended air-filled loops of bowel particularly on the right side of the obdomen, in the middle and left side bowel loops were almost absent. Because of this findings, suspected for an space occupying process displacing and obstructing the obwel, a CT scan was performed.
Abdominal plain films
Abdominal plain film, erect position. Slightly distended air-filled loops of bowel with air-fluid levesl particularly on the right side of abdomen.
Figure 2

CT-scan, native

CT-scan, native
Massive widening of the left rectus sheath with hyperdense areas,highly suspicious for a hematoma.
CT-scan, native
Between hyperdense areas of this lesion there could be seen air-filled areas, and it showed very close contact to the descending colon. These findings were suspected for a herniation of bowel into the abdominal wall. There was no recent history of trauma, so we thought of a malignant process infiltrating into the abdominal wall too.