IMAGES IN MEDICINE

Spontaneous evisceration through an umbilical hernia in an adult

Nicole R Bruton; Ludwig R Fechter; Louis Chadinha

Department of Family Medicine, Division of Emergency Medicine, Helen Joseph Hospital and Faculty of Health Sciences, University of Witwatersrand

DESCRIPTION

Bowel evisceration is an extremely rare, potentially life-threatening complication of an umbilical hernia. A 47-year-old male with a history of chronic ethanol use and a longstanding umbilical hernia presented to our emergency department with a 3-hour history of bowel protruding through his umbilicus. The patient reported that he had noted ulceration around his umbilicus in the days prior, and the evisceration occurred while straining during defecation. He had no prior surgical repair performed for his hernia.

Initial examination of the patient revealed 30cm of dusky small bowel protruding through the umbilicus with small areas showing evidence of ulceration. Emergency department management included fluid resuscitation, analgesia, broad-spectrum antibiotics, and the application of saline-soaked gauze to the eviscerated bowel. No attempt was made to reduce the evisceration due to the extent of the eviscerated bowel.

The patient was taken emergently to theatre for an explorative laparotomy during which approximately 100 cm of dusky small bowel was resected and anastomosed. The hernia sac and redundant skin, through which the evisceration occurred, were resected. The resected bowel was sent for histology, which showed mural ischaemic necrosis, complicated by acute suppurative peritonitis.

The patient subsequently developed sheath dehiscence and wound sepsis. Despite multiple relook surgeries, the patient developed septic shock and died 15 days after initial presentation.