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SAEM Clinical Image Series: Uncommon Cause of Right Groin Pain

Posted by Jason Raggi, DO on

A 48-year-old male presents with 2 weeks of severe right lower quadrant abdominal pain and inguinal pain. The patient had similar pain 2 weeks ago, was referred to a surgery clinic, but was lost to follow up. The pain has been progressively worsening over the last 2 days. It’s now severe, associated with nausea and vomiting, does not radiate, and it is worsened with coughing and sneezing. He also endorses polyuria for an unknown length of time. His last bowel movement was 3 days ago. He denies diarrhea, constipation, hematochezia, melena, dysuria, hematuria, or recent trauma.

Additional CT Images

Physical Exam

Vitals: Temp 97.7; HR 62; BP 129/84; RR 18; SpO2 99% on RA

General: Well appearing, in no acute distress, currently asking to eat food

Cardiovascular: Regular rate and rythum, no murmur

Respiratory: Lungs clear to auscultation bilaterally, no wheezes, rales or rhonchi

Abdominal: Soft, normal bowel sounds, with tenderness in the RLQ and the right groin. No rebound or guarding, no CVA tenderness, no abdominal or inguinal hernias palpated, and negative Rovsing’s sign

Genitourinary: Normal lay, circumcised, cremaster reflex intact, no testicular or epididymal tenderness, no masses, no rashes lesions or penile discharge

Labs

CBC: WBC 4.6 x 10^9/L; Hgb 11.6 g/dL; Hct 35.8%; Plt 172 x 10^9/L

BMP: Na 144 mmol/L; K 4.3 mmol/L; Cl 104 mmol/L; CO2 26.0 mmol/L; Glu 63 mg/dL; BUN 16 mg/dL; Cr. 0.82 mg/dL; Ca 9.5 mmol/L

LFT: AST 4.8 U/L; ALT 33 U/L; ALK 76 U/L

Lipase: 7 U/L

Alcohol: Negative

Urine-analysis: Unremarkable

Case Question: What is the diagnosis?

Amyand’s hernia

Appendicitis incarcerated into the right inguinal canal

Case Discussion

The CT results demonstrated Amyand’s hernia, which occurs when the appendix herniates through the inguinal ring and becomes incarcerated. Amyand’s hernia makes up less than 1% of inguinal hernias; and of all cases of appendicitis, only 0.1% present as Amyand’s hernia.

Pathological examination of the appendix found dark red and hemorrhagic segments consistent with incarceration. Definitive management is surgical removal of the appendix, and surgical consultation was immediately sought.

Take Home Points

  • In the context of abdominal and pelvic pain, appendicitis is always on the differential.
  • Appendicitis doesn’t necessarily need to present acutely.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.

Author information

Jason Raggi, DO

Resident Physician
Department of Emergency Medicine
Lincoln Hospital

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The post SAEM Clinical Image Series: Uncommon Cause of Right Groin Pain appeared first on ALiEM.

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