(P32) Strangulated Umbilical Hernia with Point-of-care Ultrasound Confirmation Presenting as Recurrent Ascites

Chief Complaint : A 37 year-old male with a history of alcohol abuse and ascites presents complaining of "I need to have my fluid tapped again."

History of Present Illness : The patient has a history of chronic alcohol abuse and was recently diagnosed with cirrhosis and ascites in the Emergency Department, but has not obtained follow-up due to lack of insurance. He has presented three times previously with abdominal pain and distention, and has had ED-performed paracentesis each time. He currently complains of abdominal fullness, pain, and umbilical protrusion which he believes is due to his recurrent ascites. This ED stay he also complains of skin changes and redness to his umbilicus which is "worsening," and he requests paracentesis.

Pertinent Physical Exam: The patients is a well-appearing male, slightly older-appearing than his stated age with mild hyperpigmentation and a grossly distended abdomen. His vital signs are within normal limits. His abdomen is tense with diffuse tenderness to palpation, but no rebound. His umbilicus is herniated with significant erythema, focal tenderness on palpation, and a distal eschar. The remainder of his exam is within normal limits.

Pertinent Laboratory Data: Laboratory evaluation showed normal chemistry with preserved renal function.
Leukocytosis was noted at 19.5 x 10^3 / mL, with normal hemoglobin and platelets.
INR was normal at 1.3.
Hepatic panel showed elevated AST (SGOT) at 1032 and ALT (SGPT) at 528 U/L, respectively.

Case Discussion: The patient underwent therapeutic paracentesis in the ED with the initial removal of 2 liters of fluid, and antibiotics were given empirically to cover for SBP. However, on re-evaluation, concern was raised for strangulated umbilical hernia. Given a several hour delay for CT, an ultrasound was performed at the point-of-care. The POCUS revealed incarcerated bowel without peristalsis and suspected pneumatosis of the bowel wall. Fluid in the hernia sac could not be attributed to bowel necrosis necessarily given the signficant ascites, and bowel wall thickening can be seen in healthy bowel if chronic ascites is present, thus these findings in this context were nonspecific. Given the clinical concern, the patient was taken to the OR where necrotic bowel was confirmed inside the hernia sac. This was then resected and repaired primarily, with likewise a primary re-anastamosis of healthy bowel. The patient did well post-operatively, with the complication of an anterior abdominal wall seroma that was managed at the bedside. This case demonstrates the danger of "anchoring" too early on the patient's-- not incorrect, but incomplete-- stated diagnosis, and failing to consider alternatives in the differential diagnosis. Further, this patient was called for CT approximately 5 minutes after skin incision in the OR for his necrotic bowel, demonstrating the need for widespread adoption and competence in point-of-care ultrasound in the acute care setting as a time (and bowel!) saving measure.

References and Acknowledgements (Optional): I gratefully acknowledge the residents and faculty of the University of Florida - Jacksonville Departments of Emergency Medicine and General Surgery for their input into this case and collegiality during my tenure there.