A Rare Case of Paraumbilical Hernia Containing and Obstructing the Stomach

Background:

Abdominal hernias occur when peritoneal lined organs protrude through the abdominal wall. They are common with an estimated prevalence of 25% in adults. Patients may be asymptomatic but surgical intervention may be advised if patients are at risk for complications such as incarceration and strangulation. Initial diagnosis of abdominal hernias is made clinically but may be assisted with imaging. Computed tomography (CT) is the current modality of choice. In this case report, we specifically focus on midline abdominal hernias. These include epigastric, paraumbilical, umbilical, and hypogastric hernias. The most frequent abdominal hernia is the paraumbilical/umbilical hernia which account for 13.9% of all hernias. These occur due to weakness or defect in the linea alba and/or abdominal rectus muscles. Patient presentation varies but many have a visible bulge that may or may not be tender to palpation. Typical contents of paraumbilical/umbilical hernias include peritoneal fat, omentum, small bowel, and large bowel. We present a unique case of stomach herniation into a pre-existing ventral abdominal hernia that has been described only a few times in the last century. Identification with CT allowed for appropriate anatomical resolution to assess for bowel obstruction and strangulation of hernia contents.

Case Presentation:

A 72-year-old female presented to the emergency department with abdominal pain, nausea, and emesis. Prior computed tomography (CT) studies completed one month before presentation showed a large, ventral abdominal paraumbilical hernia without obstruction or strangulation. However, one month later she presented with worsening symptoms of abdominal pain, nausea, and emesis. Repeat abdominal and pelvis CT showed interval herniation of the distal stomach and proximal bowel into the patient’s known paraumbilical hernia. This resulted in gastric outlet obstruction. Immediate management included intravenous fluids, nasogastric tube placement and surgical correction. Operative report revealed a large ventral abdominal hernia with viable stomach, proximal duodenum (D1), cecum, ascending and transverse colon, and multiple loops of small bowel without evidence of strangulation. The patient successfully recovered after surgery.

Conclusion:

A rare complication in paraumbilical/umbilical hernias is gastric herniation into an existing hernia. Patients may present with red flag symptoms such as abdominal pain, nausea, and emesis. Quick identification of these symptoms and rapid visualization with CT will help identify the extent of herniation and other complications such as bowel obstruction, strangulation, and incarceration. A major risk factor for gastric herniation is weakened abdominal muscles and increased laxity of stomach ligaments found in populations such as multiparous women of middle to late ages. Healthcare professionals should be aware of patients who fit this demographic to educate them on the risk of herniation and recommend them for prophylactic surgical treatment.