Presentation
Central abdominal pain, diarrhea, single episode of vomiting.
Patient Data
Antimesenteric small bowel wall trapped inside a small paraumbilical hernia. Herniating wall is thickened, suggesting incarceration*. There are several dilated small bowel loops proximal to the hernia, but no sign of complete obstruction.
Additional findings:
Sternotomy wires
Bilateral ureteral (double J) stents
Small fat-containing left inguinal hernia
Of note, injection of contrast material was avoided due to renal insufficiency.
* The hernia was indeed irreducible at physical examination.
Case Discussion
At physical examination in the emergency department, the small paraumbilical hernia was irreducible. After the patient's admission to a surgical department, it was successfully reduced, with resolution of symptoms.
A Richter hernia can reduce spontaneously as well, though this may occur only after the incarcerated portion has become necrotic from strangulation. The friable necrotic wall is prone to perforation. Intrahernial perforation is contained, but if not treated promptly, may give rise to an enterocutaneous fistula. If it occurs intraperitoneally during or after spontaneous reduction, it can cause potentially life-threatening fecal peritonitis.
A Richter hernia should not cause complete bowel obstruction, as it only involves one side of the bowel wall.
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