CASE REPORT
Ultrasound-guided reduction of an incarcerated obturator
hernia in an elderly patient
Bente M. de Kok MD
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Julien B.C.M. Puylaert MD, PhD
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Frank. M. Zijta MD, PhD
Department of Radiology, Haaglanden
Medical Centre, Lijnbaan 32, The Hague,
2512 VA, Netherlands
Correspondence
Department of Radiology, Haaglanden
Medical Centre, Lijnbaan 32, 2512 VA The
Hague, Netherlands.
Email: bentedekok@hotmail.com
Abstract
Obturator hernia is a rare but clinically relevant cause of intestinal obstruction, usually found in
elderly, thin, multiparous women. It is difficult to diagnose, leading to diagnostic delay with a high
incidence of strangulation and a high mortality rate. Surgery is the only reported treatment. We
report the case of an 86-year-old woman, in whom an early diagnosis of incarcerated obturator
hernia was made with subsequent reduction by compression with an ultrasound transducer. When
the risk of strangulation is presumed to be low, ultrasound-guided reduction of an obturator hernia
is achievable and worth considering.
KEYWORDS
incarcerated hernia, intestinal obstruction, obturator hernia, ultrasonography, ultrasound-guided
reduction
1
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INTRODUCTION
Obturator hernia is a rare but clinically relevant cause of intestinal
obstruction, usually found in elderly, thin, multiparous women. It is dif-
ficult to diagnose, leading to diagnostic delay with a high incidence of
strangulation and a high mortality rate. Surgery is the only reported
treatment. We report the case of an elderly woman, in whom an early
diagnosis of incarcerated obturator hernia was made with subsequent
reduction by compression with an ultrasound (US) transducer
2
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CASE REPORT
An 86-year-old woman presented to the Emergency Department because
of diffuse, mild abdominal pain for one week, which gradually increased
over the last two days. During the last two days, she did not pass stool. In
addition, she suffered from pain in her right leg, but this was negligible
compared to the experienced abdominal pain. Besides an umbilical hernia,
for which she had undergone surgery 6 years ago, there was no history of
previous abdominal surgery or other relevant medical history.
Physical examination revealed an emaciated, frail woman with a
tender, distended abdomen. There was no clinical sign of an inguinal or
femoral hernia. There was a recurrence of the umbilical hernia, though
the contents could easily be manually reduced by the surgery resident
in the Emergency Department. This did not alter the clinical status. The
vital signs were stable. Laboratory values included a white blood cell
count of 10.7 3 10
9
/L with 84% neutrophils. C-reactive protein was
only mildly elevated with 20 mg/L (normal range 0–8 mg/L). Urinalysis
was normal. Based on the physical examination, there was a suspicion
of an ileus and urgent imaging evaluation was performed to find the
cause and rule out strangulation.
Computed tomography (CT) of the abdomen and pelvis confirmed
multiple dilated small bowel loops with air-fluid levels. Posterior to the right
pectineus muscle, a distended segment of the ileum protruded through the
obturator foramen and was trapped between the fibers of the external
obturator muscle (Figure 1). There was no evidence of free air, nor were
there radiological signs of ischemic bowel. The incarcerated loop demon-
strated normal bowel wall enhancement and normal morphology.
Even with the knowledge of the CT findings, the incarcerated her-
nia could not be palpated. Based on the clinical, laboratory, and CT
findings, the risk of strangulation was considered low. Because of the
age and poor general condition of the patient, the surgeon assessed
the risk for potential significant complications during surgery higher
than the risk of having an ischemic bowel. He asked the radiologist to
attempt a US-guided reduction.
On a sagittal view at the medial aspect of the upper thigh, using an
Aplio 500 scanner with a 3.6–9.2 MHz convex transducer (Toshiba
Medical, Tustin, CA), the incarcerated small bowel segment was easily
identified, with normal echotexture and without bowel wall thickening,
and the hernia orifice was clearly visualized (Figure 2A). Color Doppler
US revealed no intramural flow. There was a small amount of free fluid
J Clin Ultrasound. 2018;46:415–418. wileyonlinelibrary.com/journal/jcu
V
C
2017 Wiley Periodicals, Inc.
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415
Received: 1 May 2017
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Revised: 16 October 2017
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Accepted: 30 October 2017
DOI: 10.1002/jcu.22562
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