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Image of the Month—Quiz Case

Image of the Month—Quiz Case A 61-year-old woman with a history of bilateral pyelonephritis and a nonfunctioning right kidney developed end-stage renal failure. She started chronic hemodialysis via a polytetrafluoroethylene dialysis fistula in the right lower arm in October 2006. Her medical history also included morbid obesity, type 2 diabetes mellitus, and a cholecystectomy. She was evaluated for a renal transplant. During this evaluation, she noted an expanding mass she had had for years on the left side just above the iliac crest. This mass gave intermittent episodes of muscular pain and a heavy feeling in the left flank. On clinical examination, we found that she had a body mass index (calculated as weight in kilograms divided by height in meters squared) of 41, classifying her as morbidly obese. She had reducible swelling with a diameter of approximately 10 cm in the left flank. The swelling increased in size with straining and Valsalva maneuver. There were no other abnormalities. The edges of the swelling were indistinguishable from the surrounding soft tissue on clinical examination. A computed tomographic scan of the abdomen revealed a protrusion of abdominal contents through the muscular layers of the lumbar region. This protrusion lay posterior to the oblique muscles of the abdomen, anterior to the quadratus lumborum muscle, and superior to the iliac crest (Figure 1 and Figure 2). View LargeDownload Figure 1. Transverse computed tomographic image showing a breach in the abdominal wall with protrusion of abdominal content in the left lumbar area. View LargeDownload Figure 2. Coronal reconstruction of computed tomographic scan showing a breach in the abdominal wall directly above the iliac bone. H indicates head; L, left; and R, right. What Is the Diagnosis? What Is the Diagnosis? A.  Spigellian hernia What Is the Diagnosis? B.  Lumbar hernia in the triangle of Petit What Is the Diagnosis? C.  Sciatic hernia What Is the Diagnosis? D.  Lumbar hernia in the triangle of Grynfeltt What Is the Diagnosis? Answer http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Image of the Month—Quiz Case

Abstract

A 61-year-old woman with a history of bilateral pyelonephritis and a nonfunctioning right kidney developed end-stage renal failure. She started chronic hemodialysis via a polytetrafluoroethylene dialysis fistula in the right lower arm in October 2006. Her medical history also included morbid obesity, type 2 diabetes mellitus, and a cholecystectomy. She was evaluated for a renal transplant. During this evaluation, she noted an expanding mass she had had for years on the left side just above...
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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2011.663a
Publisher site
See Article on Publisher Site

Abstract

A 61-year-old woman with a history of bilateral pyelonephritis and a nonfunctioning right kidney developed end-stage renal failure. She started chronic hemodialysis via a polytetrafluoroethylene dialysis fistula in the right lower arm in October 2006. Her medical history also included morbid obesity, type 2 diabetes mellitus, and a cholecystectomy. She was evaluated for a renal transplant. During this evaluation, she noted an expanding mass she had had for years on the left side just above the iliac crest. This mass gave intermittent episodes of muscular pain and a heavy feeling in the left flank. On clinical examination, we found that she had a body mass index (calculated as weight in kilograms divided by height in meters squared) of 41, classifying her as morbidly obese. She had reducible swelling with a diameter of approximately 10 cm in the left flank. The swelling increased in size with straining and Valsalva maneuver. There were no other abnormalities. The edges of the swelling were indistinguishable from the surrounding soft tissue on clinical examination. A computed tomographic scan of the abdomen revealed a protrusion of abdominal contents through the muscular layers of the lumbar region. This protrusion lay posterior to the oblique muscles of the abdomen, anterior to the quadratus lumborum muscle, and superior to the iliac crest (Figure 1 and Figure 2). View LargeDownload Figure 1. Transverse computed tomographic image showing a breach in the abdominal wall with protrusion of abdominal content in the left lumbar area. View LargeDownload Figure 2. Coronal reconstruction of computed tomographic scan showing a breach in the abdominal wall directly above the iliac bone. H indicates head; L, left; and R, right. What Is the Diagnosis? What Is the Diagnosis? A.  Spigellian hernia What Is the Diagnosis? B.  Lumbar hernia in the triangle of Petit What Is the Diagnosis? C.  Sciatic hernia What Is the Diagnosis? D.  Lumbar hernia in the triangle of Grynfeltt What Is the Diagnosis? Answer

Journal

Archives of SurgeryAmerican Medical Association

Published: May 1, 2012

Keywords: renal transplantation,edema,kidney failure, chronic,diabetes mellitus, type 2,cholecystectomy,physical examination,hernias,obesity, morbid,polytetrafluoroethylene,pyelonephritis,reconstructive surgical procedures,valsalva maneuver,abdomen,medical history,abdominal wall,myalgia,lumbar hernias,hemodialysis,iliac crest,quadratus lumborum muscle,sciatic hernia,kidney, right,arm,ilium,body mass index procedure

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