Case

A 45-year-old presents with a small lump at their right groin. They indicate a painless lump has occasionally appeared and disappeared at that site in the past year, but the small lump is now continuously present. In the last few days the lump has recently become painful, and the area is very tender to the touch with localized erythema.  The patient has normal bowel movements and bowel sounds are unremarkable. The patient has a temperature of 38.5°C, respiratory rate of 30 breaths/minute, pulse of 110 beats/minute and blood pressure of 80/60mmHg. The patient's response to questions is slow and a few times during interview requires repeating the question.   

Question 2/3 - What condition(s) have emerged over the past days?

Click on your selected option(s) below  (correct = 2, over-thinking = 3+)

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Correct! A Richter's hernia is one in which part of the wall of the bowel has become incarcerated, and may progress to strangulation resulting in ischemia.

The presence of pain, erythema, and sepsis suggest the wall has become ischemic with entry of microorganisms widely through the body from this site.

In a Richter's hernia involves only part of the wall of the bowel becoming entrapped, which means normal bowel movements can occur in the remaining luminal region consistent with the mostly normal movements/sounds of this patients GI tract.

Partially correct. A strangulated hernia is one in which the construction has cut off blood supply resulting in potential or occurring ischemia of the intestinal loop.

In this situation the bowel cannot function when the tissue has become ischemic, so the presence of normal bowel movements and gas sounds in this patient indicate the condition cannot be a typical strangulated hernia. But partially correct, as some strangulation is involved.

Incorrect. An incarcerated hernia has become 'stuck', but remains healthy tissue. While the patients hernia did indeed become incarcerated, it has progressed past this stage and incarceration would not be the most accurate diagnossis 

Incorrect. The patient is exhibiting a fever and signs of systemic problems that do indicate injury/ischemia to the bowel. However, we have strong suspicion the inguinal lump that has become painful and exhibit erythema is involved, findings not consistent with isolated  ischemic colitis.

We might keep ischemic colitis in the back of the mind, but it's unlikely for two fully independent conditions to emerge simultaneously that share features, the developing hernia progression and an ischemic colitis at the same time. 

Correct! The patient is exhibiting a fever and all three of the signs of sepsis.

These signs include any 2 of 3 from, (1) presence of hypotension with the patient's low 80/60 blood pressure, (2) tachypnea with rapid shallow breathing over 20/min, and (3) altered mentation with the slow response and need for question repetition. 

Incorrect. While a lymphoma is possible in the inguinal lymph nodes and are painless, these are rarely large enough to make a visible lump so would still not be consistent with the findings.