Inguinal Hernia

An 80-year-old female presented to the emergency room with constipation, a 50 lb weight loss over 3 months, and difficulty ambulating secondary to 2 large inguinal hernias. Her past medical history was significant for a total abdominal hysterectomy for menorrhagia and fibroids and schizophrenia. She had not seen a doctor since 1992.

Physical examination. Her physical exam was notable for bilateral inguinal hernias, which were not reducible (Figure 1). 

Figure 1. Bilaterial inguinal hernias.

Laboratory results. Her laboratory results were notable for a white cell count of 366,000, hemoglobin of 6.8, and hematocrit of 22.6. The differential was notable for 88% lymphocytes, 2% atypical lymphocytes, and 8 prolymphocytes. 

The patient underwent a CT scan of the abdomen and pelvis with intravenous contrast, which showed large bilateral inguinal hernias containing non-obstructed colon in the right and non-obstructed small bowel in the left. Numerous intraperitoneal and retroperitoneal masses measuring up to 8 cm were noted (Figures 2 and 3).

Flow cytometric analysis of the peripheral blood sample, after preferential gating of cells (CD45 bright gate, 88% of all cells analyzed), shows a predominant lambda-restricted B-cell population (98% of gated lymphoid cells) with the following immunophenotype: CD19+, CD20 dim, Cyt. CD79a+, FMC7-/dim-partial, CD5+, CD23+, CD10-, CD38 mostly -, CD43+, HLA-DR+, sIgM/D overall dim, CD103-, CD25-, CD34-, TdT-, and CD30-. These findings are consistent with chronic lymphocytic leukemia/small lymphocytic lymphoma.

Figures 2 and 3: Coronal and axial images. 

Diagnosis. The patient declined further workup and treatment as an inpatient. She was discharged to home with outpatient follow-up for presumed chronic lymphocytic leukemia/small lymphocytic lymphoma.

Discussion. Inguinal hernias are a common condition for which primary care physicians refer patients for surgical management. Hernias are typically diagnosed by physical examination as a bulge in the groin area that can become more prominent when coughing, straining, or standing up. There are currently no medical recommendations about how to manage inguinal hernia. The risk of incarceration or strangulation is less than 3% per year. Asymptomatic inguinal hernias can remain untreated. A hernia without unusual clinical features does not require any other investigation, except in female patients. Ultrasound is recommended to exclude a femoral hernia. CT scan generally has little role in the diagnosis of inguinal hernia though it has a sensitivity of 83% and a specificity of 67% to 83%.

In this case, the unusual size of the hernias, profound weight loss, and lymphocytosis necessitated the ordering of a CT of the abdomen and pelvis. For most cases of inguinal hernias, the physical examination is usually enough to make the diagnosis.  ■

References:

1. Simmons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society Guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13:343-403.

2. Højer AM, Rygaard H, Jess P. CT in the diagnosis of abdominal wall hernias: a preliminary study. Eur Radiol. 1997;7(9):1416-1418.