(P21) Worming It’s Way In

Chief Complaint : A 67-year-old male with a history of bilateral inguinal hernias presented complaining of worsening pain and swelling over the right inguinal area for 3 days.

History of Present Illness : A 67-year-old male with a history of COPD, atrial fibrillation, and bilateral inguinal hernias presented complaining of worsening pain and swelling over the right inguinal area for 3 days. The patient stated he had bilateral inguinal hernias for the past 4 years. He reported the right side has progressively enlarged and became intermittently painful over the past 3 months. The pain acutely worsened and has been more persistent since 3 days ago. Patient denied fever, abdominal distension, nausea, or vomiting. Patient reported his last bowel movement was the day prior to presentation. Patient has no prior abdominal surgeries.

Pertinent Physical Exam: General: middle aged male in no acute distress, but appeared uncomfortable.
Cardiovascular: regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, gallops.
Respiratory: Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
Gastrointestinal: Abdomen soft, non-distended, non-tender, no guarding or rebound tenderness.
Genitourinary: Large bilateral scrotum. Soft large left inguinal mass palpated. Firm large right scrotal mass that is tender to palpation. Fullness to the right inguinal canal that is tender to palpation. No overlying skin changes to the scrotum.
Extremities: moving all extremities. No pitting edema.
Neurological: Alert and oriented to person, place, and time.

Pertinent Laboratory Data: His vital signs, white blood cell count, and lactate were within normal limits.

Case Discussion: Amyland's hernia is when the appendix, whether or not it is inflamed, is found within the inguinal hernia sac. It is a rare finding and occurs in about 0.5% of inguinal hernias. It is typically mistaken as an incarcerated or strangulated hernia and is difficult to diagnose clinically. The presenting symptoms can be varied, from mild abdominal pain to signs of bowel obstruction. The diagnosis is traditionally made intraoperatively, but ultrasound and computed tomography (CT) imaging have been helpful modalities for preoperative diagnosis. In the CT imaging of our patient, there was no evidence of appendicitis or bowel obstruction. Of note, our patient also has a left inguinal hernia containing the sigmoid colon.

Treatment depends on whether or not there is evidence of appendicitis. If the appendix is not inflamed, bedside hernia reduction should be performed. If reduction is unsuccessful, treatment is hernioplasty with or without appendectomy. If there is evidence of appendicitis, treatment is hernioplasty with appendectomy. In our case, general surgery evaluated the patient in the emergency department and was able to reduce bilateral inguinal hernias at bedside. There was no indication for urgent surgical repair and he had an outpatient follow up general surgery appointment scheduled.

References and Acknowledgements (Optional): 1. Michalinos A, Moris D, Vernadakis S. Amyand's hernia: a review. Am J Surg. 2014 Jun; 207(6):989-95.
2. Ash L, Hatem S, Ramirez GA, Veniero J. Amyand's hernia: a case report of prospective ct diagnosis in the emergency department. Emerg Radiol. 2005 Jun;11(4):231-2.
3. Keskin S, Simşek C, Keskin Z. The Amyand's Hernia: A Rare Clinical Entity Diagnosed by Computed Tomography. Case Rep Radiol. 2013;2013:638270.