STRANGULATED INTERNAL HERNIA SIMULATING APPENDICITIS*

V. L. SCHRAGER, M.D., P.A.C.S.

Assistant Professor of Surgery, Northwestern University Medical SchooI

AND

A. B. RAGINS, M.D.

Assistant Resident Pathologist, Cook County Hospital

CHICAGO

M ANY pathoIogica1 processes in and about the iIeoceea1 region are obviousIy diagnosed appendicitis.

In a fair percentage of cases the onIy excuse for such a diagnosis is topographica1, as a thorough cIinica1 appraisa1 of the sequence and the degree of symptoms wiI1 often make a diagnosis of appendicitis. There are, however, a number of entities in McBurney’s zone which wiI1 tax the acumen and experience of even seasoned clinicians.

Internal strangulated hernias about the ileoceca1 region are invariably diagnosed acute appendicitis, especiaIIy those which become stranguIated in one of the severa pericecaI and pericohc fossae. Steinke,’ reviewing the Iiterature of internal hernias between the years of 1925 and 1932, cites 7 cases of stranguIated periceca1 hernias, the stranguIation being either in one of the fossae or in a mesentery sht, a11 of which were diagnosed appendicitis. Pribramz cites the case of a man fifty years oId who suffered from chronic constipation and had at various times paroxysms of abdominal pain and vomit- ing. One day he had a A are-up of abdomina1 pain in the right iIeac fossa associated with vomiting, which assumed the picture of appendicitis. ExpIoratory Iaparotomy re- veaIed 235 cm. of stranguIated, gangrenous smaI1 intestine in a retroceca1 fossa.

The appendix was grossly normal. The gangrenous segment was resected and the patient made a perfect recovery. Traum3 reports a case of a patient who had never been iI previously and who was suddenIy seized with abdomina1 pain in the right iIeac fossa, vomiting and inabiIity to defecate or pass flatus. A diagnosis of appendicitis was made. (We feel that the sudden pain in the right iIeac fossa, from the very start, associated with inabiIity to pass flatus or defecate shouId have suggested intestina1 obstruction).

Occasionally the appendix is a part of the pathoIogy, as in the case reported by ZoepfeL4 The patient, a maIe eighteen years of age, had an incarceration of the entire smaI1 intestine in a retroceca1 recess. The appendix was perforated and was a part of the pathoIogy.

Several cases were reported by MuIIer,5 Stech,G MaIcomb,’ Deaver and Burden,s MartzIoff,g and Vidgoff and Sturgeon,l’ in which a preoperative diagnosis of acute appendicitis was made, but upon explora- tion proved to be stranguIated interna hernias.

CoIey and Hoguet” came cIoser than many other cIinicians to the correct preoperative diagnosis. A case reported by them was diagnosed retroperitonea1 hernia before the operation, which proved to be a hernia in the retroceca1 fossa.

* From the surgical service of Dr. V. L. Schrager, Cook County Hospital, Chicago, Illinois. Read before the meeting of The Chicago Surgical Society.

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NEW SFRIFS VOL. XXIX, No. z Schrager & Ragins-Hernia American Journal of Surgery 307

CASE REPORT

The patient, a coIored male, thirty-three years of age, a cab driver, was admitted to the Cook County HospitaI on February I I, 1933,

with the examining room diagnosis of acute appendicitis.

In the ward, the interne obtained the foIIow- ing history :

The patient was entireIy we11 unti1 the day of entrance, when about 930 P.M. he was seized with a sharp, crampIike pain in the Iower quadrant followed by a desire to move his howeIs. Driving his cab intensified the pain, and he was compeIIed to go home. The severe abdomina1 pains recurred every few minutes, while the pain remained IocaI at a11 times. Nausea was entireIy absent. At home he took sa1 hepatica three times, each dose being folIowed by vomiting. He was abIe to pass gas but not abIe to move his boweIs. At 3 A.M. he was admitted to the Cook County HospitaI.

There was nothing relevant in the past Jlistory that had any bearing upon the present condition.

Physical examination reveaIed a coIored maIe, who did not appear ill. Temperature 99%., puIse rate about 70 and respiration 18. Examination of chest was essentiaIIy negative.

The abdomen was moderateIy distended. There was rigidity and Iocalized tenderness in the right ileac fossa, and there was a paIpable mass which was distinctIy noticeabIe on inspection.

The urinaIysis was negative in a11 respects. The Ieucocyte count was IS,OOO with a high poIgmorphonucIear count. The junior interne made a diagnosis of acute appendicitis, and the patient was referred for surgery.

Operation. McBurney’s incision was made. Upon opening the peritoneum, a mass was paIpated which adhered to the parieta1 peri- toneum and was located midway between the anterior superior spine and the spine of the pubis. The mass was readily brought up into view, revealing a Ioop of small intestine of dark red hue contrasting with the normal bowel. The mesentery of the involved bowe1 showed extensive vascular damage. The freed portion of the boweI became viabIe, in a short time, and was returned to the peritoneal cavity without resection. On the media1 aspect of the cecum there was a rent in the serosa, 1.14 inches, which constituted the hernia1 pocket and

readiIy admitted two fingers. The edges of the rent were indurated and infIamed.

The pathoIogic picture was that of an

FIG. I. Artist’s drawing of hernia as seen in abdominal cavity. A, Opening into hernia1 sac. 8, ProximaI Ioop of iIeum as it enters hernia1 sac. c, Hernia1 sac. D, Appendix. E, IIeum as it enters cecum. F, Cecum.

internal stranguIated hernia, a loop of smaI1 intestine being tightIy engaged into a rent in the waI1 of the cecum. (Fig. I.)

The appendix was grossIy normal and was removed routineIy.

The patient made an uneventfu1 recovery and Ieft the hospita1 on the nintJl postoperative day.

SUMMARY COMMENTS

StranguIation or incarceration of internal hernias takes pIace either in the superior or the inferior iIeoceca1 fossa, the retrocolic fossa, or in the iIeoappendicular fossa. These hernias occur most commonIy in the retroceca1 fossa, as shown in the history reports by Short,lz in which 17 cases were retroceca1 as compared with 5 iIeoappendicuIar hernias. Some Iess com- mon types of stranguIations have been reported by Traum,” in which the strangu- Iation took pIace in one of the recesses occassionaIIy found in the ascending or descending coIon. In his case, there was no evidence of infiammation at the mouth of the sac. In our case, however, there were distinct inflammatory changes in the

308 American Journal of Surgery Schrager & Ragins-Hernia AUGUST. ,933

serosa of the cecum. By way of conjecture, interna stranguIated hernias in the right we beIieve that the sac in our case was traumatic ‘in origin, since the patient had

iIeac fossa, usuaIIy diagnosed appendicitis. However, if the cIinician wouId take a

no previous evidence of obstruction, aI- painstaking inventory of the quaIity and though the possibiIity of a congenita1 sac, the sequence of the symptoms, as stressed occurring in that particuIar area, cannot by John B. Murphy13 in his cIassic articIe, be ruIed out. “Two Thousand Cases of Appendicitis,”

We are tempted to report this case, he wouId invariabIy come cIoser to an because it faIIs in the common group of accurate diagnosis.

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* Continued from p. 207.