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Case 34 

Case 34
Chapter:
Case 34
Author(s):

Ellen Chung

DOI:
10.1093/med/9780199758968.003.0034
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History

  • 2-week old with abdominal distention and emesis.

Diagnosis

Case 34 Small Bowel Obstruction/Incarcerated Umbilical Hernia

Findings

  • AP (left) and lateral (right) radiographs demonstrate multiple dilated tubular loops of bowel (arrow) consistent with obstruction. Also noted is a sharply circumscribed soft-tissue density (arrowhead) representing an umbilical hernia surrounded by air, which is the cause of the obstruction.

Differential diagnosis

The most common cause of small bowel obstruction in adults is postsurgical adhesions, but these are uncommon in children. More common causes of bowel obstruction in infants and young children are intussusception and incarcerated hernias. Less common causes include midgut volvulus, Ladd bands, appendicitis, and tumors.

Teaching points

  • Umbilical and inguinal hernias are very common in children. Umbilical hernias are clinically obvious and rarely become incarcerated, so they do not pose a diagnostic question for the radiologist.

  • Inguinal hernias in children are indirect and 90% occur in boys. Premature infants have an increased risk. Inguinal hernias may become incarcerated and should be surgically repaired.

  • Plain radiographic findings of inguinal hernia in a child include asymmetry of the inguinal folds and air projecting over the inguinal region on a supine radiograph.

  • Sonography is the study of choice for suspected inguinal hernia. Bowel is the most common abdominal structure to herniate into the inguinal region, but mesenteric fat, ascitic fluid, and even ovaries can also herniate. Color Doppler interrogation of the wall of the herniated bowel is helpful for the surgeon.

Next steps in management

The treatment for bowel obstruction in children is surgical unless the obstruction is caused by an ileocolic intussusception in a child in the proper age group for idiopathic intussusception. In such a case, reduction by contrast enema may be attempted. The watchful waiting that is employed with adults is not appropriate for children.

Further reading

1. McCollough M, Sharieff GQ. Abdominal pain in children. Pediatr Clin North Am. 2006 Feb;53(1):107–137, vi.Find this resource:

2. Graf JL, Caty MG, Martin DJ, Glick PL. Pediatric hernias. Semin Ultrasound CT MR. 2002 Apr;23(2):197–200.Find this resource: