Catheter balloon mimicking incarcerated femoral hernia and co-existing small bowel diverticular perforation: a case report
© Reeve et al.; licensee Cases Network Ltd. licensee BioMed Central Ltd. 2009
Received: 23 July 2009
Accepted: 19 August 2009
Published: 15 September 2009
The majority of patients with small bowel diverticula are asymptomatic, however, associated complications include inflammation, intestinal obstruction, perforation and gastrointestinal haemorrhage. Bladder divertulae are uncommon and can herniate into the femoral or inguinal canal as well as the scrotum. We report the case of an elderly lady who underwent laparotomy for an incarcerated femoral hernia and was found to have the catheter balloon stuck into a bladder diverticulum in the femoral canal and coexisting small bowel diverticular perforation.
Small bowel obstruction has many causes including adhesions, hernias, malignancy and inflammatory bowel disease. A common cause of small bowel obstruction and bowel strangulation is femoral herniation of the small bowel . Hernias have been found to be the most common cause of bowel strangulation . Extremely rarely diverticular disease of the small bowel may be complicated by small bowel obstruction.
Due to the rarity of small bowel diverticular complications, this is not the first diagnosis entertained for a patient presenting with obstruction, bleeding or an acute abdomen. This can lead to some delay in diagnosis and definitive treatment. The most useful imaging technique for diagnosing small bowel diverticulosis is CT scanning, however the disease often only presents at laparotomy . Small bowel diverticula commonly occur in the duodenum, however only around 2% of the population have jejunal diverticula [4, 5]. Jejunal diverticula have a higher rate of complication than duodenal diverticula, suggesting that pre-emptive surgical removal on discovery may be preferable in comparison to conservative management . The formation of strictures secondary to jejunal diverticular disease has previously been reported to be complicated by small bowel obstruction . One of the many complications of small bowel diverticula, along with obstruction, includes perforation. This is generally treated surgically with laparotomy and bowel resection. However, non-surgical management is a further option with either sole antibiotic treatment or diverticular-associated abscess drainage .
Herniation of the urinary bladder wall is uncommon. The incidence of groin hernia containing the urinary bladder has been shown to be around 0.36%, although higher incidences have been reported . Often such hernias can be associated with iatrogenic bladder injury at the time of surgery. Bladder herniation most commonly occurs through the inguinal and femoral canals. Causal factors of bladder herniation include pelvic space-occupying lesions, urinary outlet obstruction and obesity leading to increased intra-abdominal pressures.
A high index of suspicion of the content of groin hernia is required to avoid iatrogenic injury to abdominal organs. Although unusual contents of groin hernias, such as the bladder, can be picked up by imaging, such as excretory urography, the likelihood is that the contents are only delineated at surgery . From review of the literature, no examples of urinary catheters housed in bladder diverticulae have been the cause of supposed incarcerated femoral hernias prior to this case.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of consent is available for review by the Editor-in chief of this journal.
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