(P94) Richter Hernia Detected by Point-Of-Care Ultrasound

Chief Complaint : The patient complains of worsening, dull, abdominal pain for 3 days.

History of Present Illness : A 21-year-old gravida 3 para 2 female who presented to the emergency department for worsening, dull, abdominal pain for 3 days. She was concerned that she was having this pain as she is pregnant and come to the emergency department for evaluation. She denies fever, diarrhea, dysuria, nausea/vomiting vaginal bleeding, and vaginal discharge.

Pertinent Physical Exam: GENERAL: Healthy appearing, well-developed.
PSYCH: Alert and Oriented to person, place and location. Normal memory, mood, and affect.
HEENT: Normocephalic, atraumatic, pupils equal and reactive bilaterally, Moist mucous membranes
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally, no wheezing.
ABDOMEN: Abdominal tenderness
SKIN: Warm, well perfused. No skin rashes or abnormal lesions.
MSK: No deformities or signs of scoliosis. Normal gait.
NEURO: Ambulating with no limitations. Normal muscle strength and tone. No focal deficits.

Vital signs included: blood pressure 105/59mmHg, heart rate 75, respiratory rate 20, pulse oximetry 100%, and temperature 36.8℃.

Pertinent Laboratory Data: Pertinent laboratory values included positive beta-hCG.

Case Discussion: Transvaginal ultrasound depicted an intrauterine pregnancy with fetal heart tones and an estimated gestational age of 9 weeks. Abdominal bedside ultrasound showed a ventral hernia with bowel peristalsis within the hernia. Surgery was consulted. Radiology ultrasound showed a Richter hernia with findings concerning for entrapment and strangulation. She underwent umbilical hernia repair with surgery. A 3x2 cm fascial defect was noted and primary repair was performed.

This case provides evidence for the utility of point-of-care ultrasound (POCUS) in hernia diagnosis. POCUS recognized the diagnosis for a Richter’s hernia based upon visualization of peristalsis within the hernia compartment. Steinke et al. used 18 prospectively collected cases and a literature review to outline that Richter's hernia is a deceptive entity whose high death rate can be reduced by accurate diagnosis and early surgery (1). A meta-analysis of 23 studies of radiology-performed ultrasound of occult inguinal hernias in adults demonstrated a pooled sensitivity of 86% and a specificity of 77%, outperforming computed tomography's 80% and 65%, respectfully (2). This case further indicates POCUS as a safe, effective, and inexpensive medium for hernia diagnosis (3).

Additionally, Richter’s hernias are known to develop at laparoscopic sites (4). As the rate of laparoscopic procedures increase, EP’s should include Richter’s hernia on the differential diagnosis for abdominal protrusion patients. Prompt and accurate diagnosis of Richter’s hernia reduces associated morbidity. This patient had an unremarkable post-operative course. This case demonstrates that point-of-care ultrasound is an emerging diagnostic imaging modality to expedite the diagnosis and management of undifferentiated hernias. Ultrasound was critical for diagnosis in this patient due to her pregnancy as she was unable to get a CT scan.

References and Acknowledgements (Optional): 1. Steinke W, Zellweger R. Richter's hernia and Sir Frederick Treves: an original clinical experience, review, and historical overview. Ann Surg 2000; 232:710.

2. Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc. 2013;27(1):11-18.

3. Guidelines for diagnostic imaging during pregnancy and lactation. Committee Opinion No. 723. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e210–6

4. Callery MP, Strasberg SM, Soper NJ. Complications of laparoscopic general surgery. Gastrointest Endosc Clin N Am. 1996;6(2):423-444.