Gangrenous appendicitis in a strangulated obturator hernia.

Abstract: Only two cases of appendicitis in strangulated obturator hernia have been previously reported. In the present case, an 83-year-old woman had fatal anaerobic myonecrosis of the thigh that resulted from gangrenous appendicitis in the right obturator foramen. Early diagnosis, prompt surgical intervention, and perioperative resuscitation are critical for survival in a case of appendicitis in a strangulated obturator hernia with thigh sepsis, especially when it occurs in an elderly, emaciated female patient.

Key Words: appendicitis, myonecrosis, obturator hernia, surgery, vermiform appendix

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Obturator hernia is the most frequently encountered pelvic floor hernia. Watson (1) collected 442 cases in 1946, and more than 400 additional cases have been identified by a 1966-through-2002 MEDLINE database search. Obturator hernia is manifested as small bowel obstruction in nearly 90% of patients (2,3) and is therefore difficult to distinguish from other, more common conditions such as adhesions and cancer. Sophisticated radiologic modalities such as computed tomography (CT) can reliably make the diagnosis of obturator hernia in up to 90% of patients and avoid misdiagnosis. (4) Unfavorable outcome is most often associated with delay in presentation and diagnosis, the condition's prevalence in debilitated elderly patients, and a high rate of intestinal gangrene. (5)

Discussion

Obturator hernia is subject to confusion and diagnostic delay and has been regularly cited as obscure and puzzling. A recent review of the surgical profession's experience with obturator hernia showed lack of consensus about the diagnosis and treatment of this dangerous condition. (5) Most patients with obturator hernia present with some of the condition's classic features, including female sex, advanced age, and lean body habitus. (1-3,5) Specific signs of strangulated obturator hernia include obturator neuralgia (hypoesthesia or hyperesthesia or cramp from the inguinal crease to the anteromedial aspect of the thigh); Howship-Romberg sign (pain in the medial thigh or in the hip exacerbated by extension, adduction, or medial rotation); and Hannington-Kiff sign (absent adductor reflex in the thigh). (1,2) The diagnosis is elusive when these signs are absent or cannot be elicited, as in our patient, whose severe general condition precluded a detailed history and interactive physical examination. Sophisticated radiologic modalities such as CT, ultrasonography, and magnetic resonance imaging can reliably make the diagnosis of obturator hernia; CT is now regarded as the standard diagnostic modality. (3)

Bedside abdominal ultrasonography is useful if a strangulated hernia is suspected. It provides accurate assessments of the groin and pelvic areas, obstruction level, possible involvement of the large bowel, and presence of peristalsis. (6) In our case, ultrasonography failed to make the diagnosis of strangulated obturator hernia, possibly because the appendix was small and the severe inflammatory reaction obscured tissue planes. Ultrasonography did show free pelvic fluid, necessitating further diagnostic workup. We used laparoscopy because this minimally invasive method was less traumatic and carried the potential of faster patient recovery, important considerations in our severely debilitated patient. An abdominal process was confirmed, but its cause remained obscure, indicating exploratory laparotomy. Laparoscopic diagnosis and management of our patient's obturator hernia was impossible because of the severe infection obscuring the pelvic anatomy. Although successful use of laparoscopy has been reported, (7) experience is too limited to recommend it as a routine procedure.

We identified two similar case reports describing appendicitis in strangulated obturator hernia. (8,9) In neither case was the correct diagnosis made preoperatively. Hartley et al (9) described an elderly female patient with fatal anaerobic thigh myonecrosis resulting from destructive obturator hernia appendicitis, similar to our patient. The similarity suggests that obturator hernia appendicitis should be suspected in elderly emaciated female patients with thigh sepsis. Early diagnosis and surgical intervention with aggressive perioperative resuscitation are key for improved patient outcome.

An ounce of practice Is worth a pound of preaching.

-John Ray

From the Department of Surgery, School of Medicine, University of Missouri--Columbia, Columbia, MO. (Dr. Kjossev is with the Department of Surgery, Military Medical Academy, Sofia, Bulgaria.)

Reprint requests to Julian E. Losanoff, MD, Department of Surgery, University of Missouri--Columbia School of Medicine. M580 HSC, One Hospital Drive, Columbia, MO 65212. Email: [e-mail]

Accepted June 26, 2002.

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9610-1042

References

1. Watson LF. Hernia Anatomy, Etiology, Symptoms, Diagnosis, Differential Diagnosis, Prognosis, and Treatment. St. Louis, C.V. Mosby, 1948, ed 3.

2. Tchupetlowsky S, Losanoff J, Kjossev K. Bilateral obturator hernia: A new technique and a new prosthetic material for repair-Case report and review of the literature. Surgery 1995;117:109-112.

3. Yokoyama Y. Yamaguchi A. Isogai M, et al. Thirty-six cases of obturator hernia: Does computed tomography contribute to postoperative outcome? World J Surg 1999;23:214-216.

4. Ijiri R, Kanamaru H, Yokoyama H, et al. Obturator hernia: The usefulness of computed tomography in diagnosis. Surgery 1996;119:137-140.

5. Losanoff JE. Richman BW. Jones JW. Obturator hernia. J Am Coll Surg 2002;194:657-663.

6. Yokoyama T. Munakata Y, Ogiwara M, et al. Preoperative diagnosis of strangulated obturator hernia using ultrasonography. Am J Surg 1997;174:76-78.

7. Tschudi J. Wagner M, Klaiber C. Laparoscopic operation of incarcerated obturator hernia with assisted intestinal resection [in German]. Chirurg 1993;64:827-828.

8. Archampong EQ. Strangulated obturator hernia with acute gangrenous appendicitis. BMJ 1969;1:230.

9. Hartley BE, Davies MS, Bowyer RC. Strangulated appendix in an obturator hernia presenting as gas gangrene of the thigh. Br J Surg 1994;81:1135.

RELATED ARTICLE: Case Report

An 83-year-old woman with insulin-dependent diabetes mellitus and multi-infarct dementia was admitted to a local hospital because of a fever of unknown origin and a rapidly deteriorating general condition over the past 2 days. Despite treatment with broad-spectrum antibiotics, lower abdominal pain and edema of the right lower extremity developed. Anticoagulation therapy was given for presumed deep vein thrombosis, but the patient's condition continued to deteriorate and she was transferred to our institution.

At arrival, the patient was in septic shock and artificially ventilated. Physical examination revealed severe muscle wasting and a soft abdomen with reduced bowel sounds. Plain films of the abdomen and chest were unremarkable. The right thigh was markedly swollen, with bluish discoloration and crepitus; radiography revealed free gas in the soft tissues. Abdominal ultrasonography showed free fluid in the right hemipelvis. Digital rectal examination was unremarkable. Findings on imaging studies and physical examination prompted diagnostic laparoscopy to look for an abdominal septic process. It revealed a small amount of greenish thick pus in the right lower quadrant. Emergency laparotomy disclosed a gangrenous appendix strangulated in a right obturator hernia. Appendectomy was done, followed by copious peritoneal lavage with warm saline. Access to the thigh compartments was gained through multiple skin incisions. Cloudy, foul-smelling, dishwater-like fluid with air bubbles escaped through the wounds. Thorough exploration of the tissue planes showed severely edematous and cyanotic muscle with multiple scattered necrotic areas. All nonviable tissue was debrided, and wounds were irrigated with hydrogen peroxide and drained. Treatment with parenteral imipenem/cilastin and metronidazole was started, together with total parenteral nutrition. The patient died on arrival at the intensive care unit. Autopsy was not done. Cultures from the abdominal pus and dead muscle grew Bacteroides and Escherichia coli.

RELATED ARTICLE: Key Points

* Appendicitis in a strangulated obturator hernia with thigh sepsis demands a high index of suspicion in elderly, emaciated female patients.

* Early diagnosis and surgical intervention in addition to perioperative resuscitation are critical for patient survival.

* Unfavorable outcome is most often associated with delay in presentation and diagnosis, advanced age and debilitation, and a high rate of intestinal gangrene.

Kirien T. Kjossev, MD, and Julian E. Losanoff, MD