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Small bowel obstruction from incarcerated direct inguinal hernia

Case contributed by Henry Knipe
Diagnosis certain

Presentation

Bowels not open for two days. Nausea.

Patient Data

Age: 90 years
Gender: Female

Dilated loops of small bowel centrally with multiple air fluid levels and a paucity of gas in the colon. Bowel gas projects over the left inguinal region. No free gas.

Left direct inguinal hernia containing normally enhancing small bowel and adjacent fluid. Proximal small bowel is dilated with multiple air-fluid levels. Distal to this small bowel is collapsed. No free gas. 

Case Discussion

Hernias are the second most common cause of small bowel obstruction (10%) but are far behind adhesional small bowel obstructions (75%), which is the major cause in developing countries. Direct inguinal hernias occur through Hesselbach's triangle, and a good differentiator from indirect inguinal hernias is that they occur anteromedial (compared to anterolateral to indirect inguinal hernias) to the epigastric vessels. 

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