CT imaging in abdominal hernia patients

[SERENITY_NOW]

Hey all,
Stupid question from an EM intern. We had a patient come in with what he thought was a ventral hernia (he felt a bulge with bearing down that we could see on exam but would immediately retract to normal after he stopped bearing down), reported severe pain and limited stooling. Thus, we CT'd him and it was read as normal, and no comment on any ventral hernia even being present, and indeed on reviewing images I didn't see any wall defect though I didn't know how easy that might even be seen. When hernias reduce, aren't you typically still able to see the wall defect it would go through? Or are they impossible to see once reduced? Trying to figure out if this guy flat out didn't have a hernia at all and what else might be causing this supposedly new abdominal bulge for him.
Thanks for your time!
SN

---

Members don't see this ad.

 

[Cognovi]

Hey all,
Stupid question from an EM intern. We had a patient come in with what he thought was a ventral hernia (he felt a bulge with bearing down that we could see on exam but would immediately retract to normal after he stopped bearing down), reported severe pain and limited stooling. Thus, we CT'd him and it was read as normal, and no comment on any ventral hernia even being present, and indeed on reviewing images I didn't see any wall defect though I didn't know how easy that might even be seen. When hernias reduce, aren't you typically still able to see the wall defect it would go through? Or are they impossible to see once reduced? Trying to figure out if this guy flat out didn't have a hernia at all and what else might be causing this supposedly new abdominal bulge for him.
Thanks for your time!
SN

The defect may not be apparent when reduced. A repeat CT with provocative maneuvers is reasonable, or possibly ultrasound. Those maneuvers would be Valsalva during the scan, with or without lying lateral decubitus. Further reading:

http://doi.org/10.2214/ajr.181.2.1810431

http://doi.org/10.2214/ajr.184.3.01840847

http://doi.org/10.1016/j.jamcollsurg.2012.11.012

In the future, if you're evaluating a reducible hernia, I would type in the requisition or talk to the protocolling radiologist about doing the scan with Valsalva, or sometimes without and then with Valsalva with possible other changes for radiation dose reduction (eg, the second time could be a limited field of view).

 

[SERENITY_NOW]

The defect may not be apparent when reduced. A repeat CT with provocative maneuvers is reasonable, or possibly ultrasound. Those maneuvers would be Valsalva during the scan, with or without lying lateral decubitus. Further reading:

http://doi.org/10.2214/ajr.181.2.1810431

http://doi.org/10.2214/ajr.184.3.01840847

http://doi.org/10.1016/j.jamcollsurg.2012.11.012

In the future, if you're evaluating a reducible hernia, I would type in the requisition or talk to the protocolling radiologist about doing the scan with Valsalva, or sometimes without and then with Valsalva with possible other changes for radiation dose reduction (eg, the second time could be a limited field of view).

Super helpful and perfectly answers my question. Thank you for sharing!

 

[SeisK]

Super helpful and perfectly answers my question. Thank you for sharing!

Basically the more info you put into the order the better. Treat the order like you would a handoff: 1) reason why they’re here, and 2) what you’re doing for them now (reason for the scan)

 

[5777]

The defect may not be apparent when reduced. A repeat CT with provocative maneuvers is reasonable, or possibly ultrasound. Those maneuvers would be Valsalva during the scan, with or without lying lateral decubitus. Further reading:

I appreciate the references, but I'm calling BS on them. The figures that are shown in the 2004 and 2005 papers actually DO SHOW the defect at rest (without the provocative maneuver). You might RARELY do a CT with provocative maneuver to see how much "stuff" actually goes through the defect, but if the CT scan at rest did not show any defect, there is no hernia. Please do not add to this patient's medical bill by ordering some bogus provocative CT or US if the CT shows an entirely intact abdominal wall.

If indeed the CT was reviewed with the understanding that you were looking for an abdominal wall defect, and there is only normal abdominal wall, it sounds like your patient has diastasis. This may or may not need surgical intervention (usually does not). This does not need another CT with provocative maneuver.

 

[Neopolymath]

Did this not look and feel like diastasis on exam? Just curious.

 

[Clean7795]

Hey all,
Stupid question from an EM intern. We had a patient come in with what he thought was a ventral hernia (he felt a bulge with bearing down that we could see on exam but would immediately retract to normal after he stopped bearing down), reported severe pain and limited stooling. Thus, we CT'd him and it was read as normal, and no comment on any ventral hernia even being present, and indeed on reviewing images I didn't see any wall defect though I didn't know how easy that might even be seen. When hernias reduce, aren't you typically still able to see the wall defect it would go through? Or are they impossible to see once reduced? Trying to figure out if this guy flat out didn't have a hernia at all and what else might be causing this supposedly new abdominal bulge for him.
Thanks for your time!
SN

There's a high chance this was just abdominal diastasis and not a hernia at all. The pain was likely a red herring and the limited stooling is unrelated in this case.

The presence of a symptomatic hernia is a clinical diagnosis. Ultrasound should rarely be done because a tiny hernia that cannot be clinically detected is unlikely of clinical concern. CT should only be done if suspected incarcerated hernia or presence of a complication (bowel obstruction/strangulation).

 

[SeisK]

I appreciate the references, but I'm calling BS on them. The figures that are shown in the 2004 and 2005 papers actually DO SHOW the defect at rest (without the provocative maneuver). You might RARELY do a CT with provocative maneuver to see how much "stuff" actually goes through the defect, but if the CT scan at rest did not show any defect, there is no hernia. Please do not add to this patient's medical bill by ordering some bogus provocative CT or US if the CT shows an entirely intact abdominal wall.

If indeed the CT was reviewed with the understanding that you were looking for an abdominal wall defect, and there is only normal abdominal wall, it sounds like your patient has diastasis. This may or may not need surgical intervention (usually does not). This does not need another CT with provocative maneuver.

You might be taking this issue a little too personally methinks.