Strangulated Umbilical Hernia

Figure

THE CASE: A 44-year-old man presents with sharp, severe abdominal discomfortthat began suddenly while he was driving to your office for a routinephysical examination. The patient reports that several days earlier he hadlifted a refrigerator. He experienced intermittent umbilical discomfort for severaldays afterwards.

Based on the clinical picture, what is the most likely diagnosis?

• Incarcerated umbilical hernia.
• Strangulated umbilical hernia.
• Acute pancreatitis (Cullen sign).
• Acute appendicitis.

Figure

DISCUSSION: This patient had astrangulated umbilical hernia andunderwent emergent operative intervention.At surgery, the herniatedbowel and omentum were dusky andrequired resection.

Some form of hernia developsin up to 10% of Americans. Herniasare associated with significant disabilityand loss of productivity and areone of the most common indicationsfor surgery, either because of intestinalobstruction (principal cause),strangulation, incarceration, or intermittentabdominal discomfort.

Incarcerated hernias may be acuteor chronic; they frequently cannot bereduced and require surgical interventionto replace the abdominal contents.Incarceration often results when thereare small defects in the abdominal walland large contents. Any process thatincreases intra-abdominal pressure(eg, chronic obstructive pulmonarydisease, constipation, or benign prostatichypertrophy) heightens the likelihoodof incarceration. Occasionally,temporary reduction of the hernia canbe achieved with firm pressure afterthe patient has been sedated.

If vascular compromise affects either the venous or arterial system, anincarcerated hernia is said to be strangulated. Pain, tenderness, and tissue discolorationin the herniated region signal the need for immediate surgical intervention.Any delay in reducing the hernia may result in gangrene. All strangulatedhernias-but not all incarcerated hernias-require surgery.

On rare occasions, discoloration around the umbilicus (Cullen sign) developsin patients with acute pancreatitis. The discoloration is secondary to peripancreatichemorrhage.

Although patients with acute appendicitis may initially complain of periumbilicaldiscomfort, no skin discoloration occurs in this region.

FOR MORE INFORMATION:

• Mullins MA. Hernia. eMedicine. Available at: www.emedicine.com. Accessed October 24, 2002.
• Sabiston DC, Townsend CM. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice.16th ed. Philadelphia: WB Saunders Company; 2001.
• Yakshe P. Acute pancreatitis. eMedicine. Available at: www.emedicine.com. Accessed October 24, 2002.