Because of the COVID19 pandemic, you are practicing medicine by telemedicine. You are shown the abdominal x-ray of a 102-year-old woman and are told she presented with a 2-day history of abdominal pain and distension, recurrent emesis, and pain radiating down her right medial thigh to her knee.
What is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, would you recommend?
DIAGNOSIS: Strangulated obturator hernia (OH).
Because of their wide pelvis and the unique shape of their obturator canal, OHs are more common in women - partcularly those that are thin and elderly and/or multiparous. The patient may be asymptomatic, or, as was true in the mystery case, present with symptoms and signs of intestinal obstruction. Compression of the obturator nerve may cause a "burning" neuropathic pain or numbness radiating from the groin to the median thigh and the knee (Howship-Romberg sign). Physical exam may reveal fullness in the femoral triangle and hypo- or hyperalgesia along the path of the obturator nerve. In women, the hernia may be detectable on pelvic examamination. The diagnosis is best confirmed with a pelvic CT scan, although ultrasound may also reveal the hernia. The treatment is surgical.