CASE 1567 Published on 20.05.2002

A patient with persistent right groin pain

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Rodrigo Salgado, Patrick Bellinck, Tom Mulkens

Patient

48 years, male

Categories

No Area of Interest ; Imaging Technique Digital radiography, Digital radiography, Digital radiography, Digital radiography

No Procedure ; No Special Focus ;

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Clinical History

A man with unexplained right groin pain. Previous examination, including US and CT, had revealed no abnormalities.

Imaging Findings

The patient was referred to our institution for the evaluation of persistent right groin pain. Initial examinations, including ultrasound and CT, could not deliver a possible cause for the symptoms experienced. The referring surgeon consequently requested peritoneography to rule out a possible occult inguinal or femoral hernia.

The first image demonstrates the examination technique (Fig. 1). The patient is placed supine on the examination table and a 22G needle is placed in the midline between the umbilicus and the anterior superior iliac spine. After local anaesthesia, approximately 60cc of a low-osmolar iodinated contrast solution is then injected into the peritoneal cavity. The correct position of the needle is illustrated by the immediate spread of the contrast medium between the bowel loops. After contrast injection the examination table is placed in a more prone position, and the patient is asked to strain in different positions. The resulting image delivers a good delineation of the supravesical fossa together with the medial and lateral inguinal fossa on both sides (Fig. 2).

In this case, after further straining a bulge of peritoneum was visualised arising from the right lateral fossa inguinal (Figs 3 and 4). A confident diagnosis was made of an indirect inguinal hernia, responsible for the persistent symptoms of the patient.

Discussion

Peritoneography (also called herniography) is a technique introduced in the 1960s with the purpose of detecting an occult inguinal or femoral hernia in children, mostly during the perinatal period. By excluding a contralateral peritoneal herniation, surgery could then confidently be limited to the affected side. Today the technique is also used in adults with unexplained and persistent groin pain, where clinical and technical examinations (mainly ultrasound and CT) fail to deliver a clear cause of the experienced symptoms. It is also used in the evaluation of recurrence after surgical repair.

Possible findings include an indirect or direct inguinal hernia, a femoral hernia and groin insufficiency (the so-called "broad fossa"). The example given in this case report is an indirect inguinal hernia, the most common of all groin hernias. They are considered to be a congenital defect caused by an open processus vaginalis. They are more common in men, who have a wider inguinal canal.

Peritoneography has proved to be very valuable for the abovementioned indications. The reported values of sensitivity and specitivity range between respectively 0.94-0.96 and 0.95-0.98 [1,4]. In our personal experience peritoneography is a very safe technique. In more than 10 years' experience with herniography at our institution, we have never had a complication that needed further significant medical attention. Other authors have further underlined the fact that a carefully performed peritoneography is a very safe and useful investigation [2,3]. Reported complications include pain at the puncture site, colon perforation and very rarely peritonitis.

An incarcerated hernia is a contra-indication for this type of examination, because of the fact that the obstruction of the neck of the hernia will prevent any contrast opacification of the peritoneal herniation.

In conclusion, in the proper clinical setting of unexplained persistent groin pain, peritoneography can deliver a possible explanation revealing an occult inguinal or femoral hernia.

Differential Diagnosis List

Indirect right inguinal hernia

Final Diagnosis

Indirect right inguinal hernia

References

[1] 1. Brierly RD, Hale PC, Bishop NL. Is herniography an effective and safe investigation? J R Coll Surg Edinb 1999 Dec;44(6):374-7. (PMID: 10612960)

[2] 2. Heise CP, Sproat IA, Starling JR. Peritoneography (herniography) for detecting occult inguinal hernia in patients with inguinodynia. Ann Surg 2002 Jan;235(1):140-4. (PMID: 11753053)

[3] 3. Shadbolt CL, Heinze SB, Dietrich RB. Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics. 2001 Oct;21 Spec No:S261-71. (PMID: 11598262)

[4] 4. Sutcliffe JR, Taylor OM, Ambrose NS, Chapman AH. The use, value and safety of herniography. Clin Radiol 1999 Jul;54(7):468-72. (PMID: 10437701)

Case information

URL:	https://eurorad.org/case/1567
DOI:	10.1594/EURORAD/CASE.1567
ISSN:	1563-4086

Figure 1

Examination technique

This image illustrates the initial phase of the examination. The correct positioning of the needle is demonstrated by the immediate spread of the contrast product between the bowel loops.

Figure 2

Initial evaluation of the peritoneogram

The radiological anatomy is nicely depicted by this technique. The different umbilical folds demarcate on both sides the fossa supravesicalis together with the medial and the lateral inguinal fossa. A peritoneal defect can already be suspected on the right inguinal fossa.

Figure 3

Indirect inguinal hernia, oblique view

With further straining, this oblique view demontrates a clear protrusion from the peritoneal cavity, consistent with an inguinal indirect hernia arising from the right lateral inguinal fossa. Note the distal widening of the herniation at the external inguinal ring.

Figure 4

Indirect inguinal hernia, profile view