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Resident PGY 3
Henry Ford Hospital
Introduction: Acute appendicitis is a common presenting clinical pathology and imaging diagnosis in everyday practice, as well as indication for surgery. CT is a sensitive first line imaging modality for assessing for appendicitis. Often assessed with ultrasound given the benefit of dynamic maneuvers, hernias are also commonly incidentally noted on CT.
Methods: Portal venous phase CT is a sensitive first line imaging modality in assessing abdominal pain and appendicitis in adults, and possible associated complications. Rarely an inflamed appendix may be located within a femoral hernia, referred to as a De Garengeot’s hernia.
Results: A 49 year-old female with past medical history notable for pulmonary hypertension on 8 liters home oxygen presented to the ER with complaints of 4 days of worsening right groin swelling and pain. Patient was noted to be febrile with tachycardia, with laboratory studies pertinent for leukocytosis. Initial concern was for an incarcerated/strangulated right inguinal hernia, and given patient medical history, she was transferred to Henry Ford Main for escalation of care. Patient underwent CT upon arrival which demonstrated a right femoral hernia, incidentally noted on remote prior imaging, with a tubular structure within the hernia sac which was new from prior and compatible with a thickened appendix associated with adjacent inflammatory changes. Patient was subsequently taken to the operating room for a laparoscopic appendectomy with right femoral hernia sac excision and femoral hernia repair. Pathologic analysis of the obtained surgical specimen confirmed the diagnosis of acute appendicitis with hernia sac congestion and inflammation.
Conclusions: De Garengeot’s hernia is a rare and clinically difficult to diagnose entity. Femoral and inguinal hernias are difficult to differentiate clinically, with nonreducible strangulated hernias associated with swelling and pain. CT imaging is an important tool to aid in the diagnosis and classification of groin hernias, and even more so in assessing for appendicitis and possible complications including the rarely seen De Garengeot hernia.
Wrubel, Allen; Heilala, Adam; and Kramer, Jason, "A Painful Protrusion – A Rare Presentation of Appendicitis" (2020). Case Reports. 4.