Umbilical Hernia

Case History: Pregnant female, 21 weeks 3 days gestational age, G2P1, experiencing severe peri-umbilical pain and a palpable bump just to the right of the umbilicus. There was no history of blunt trauma to the abdomen, but had history of hernia repair surgery approximately two years prior to this hospital visit. No lab values were available, but those that would have been beneficial would be a white blood cell count and beta hCG. A limited obstetric ultrasound was ordered to check the wellbeing of the fetus, as well as an evaluation of the area of pain and bump.

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Figure 1. A Philips iU22 machine with a 5 MHz curved transducer was used for this portion of the exam. The placenta, amniotic fluid index, heart rate, biometry measurements and the cervix were evaluated first. The heart rate was within range at 140 beats per minute, as well as the fluid appearing within normal limits. No abruption in the placenta was noted.

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Figure 2. The placenta was imaged in both longitudinal and transverse imaging planes and extreme care was taken to be sure there were no signs of abruption or fetal distress.

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Figure 3. Upon careful demonstration of the placenta, it was noticed that the area directly anterior to the uterine wall appeared hypoechoic and heterogeneous. This image is right over the area of pain. The color Doppler box shown here demonstrates no color flow within the area of interest.

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Figure 4. Still using the curved transducer, the depth was decreased to get better visualization of the area of interest. This is a longitudinal (right) and transverse (left) image just to the right of the umbilicus, and the area of the patient’s pain.

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Figure 5. Since the area of interest was so superficial, a linear high frequency transducer (12 MHz) was used for these images. This shows the area of the patient’s pain, just to the right of the umbilicus in the longitudinal and transverse planes. This image is directly over a palpable lump.

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Figure 6. The area appears well-circumscribed, anechoic and peristalsis was noted within the parenchyma in real-time scanning. The anechoic area was measured in the transverse and longitudinal plane, measuring 2.95 × 2.72 × 2.15 cm.

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Figure 7. Color Doppler was put on the images to show blood flow visualized within the outer hyperechoic “walls” of the well-circumscribed area.

Diagnosis: Umbilical hernia.

Discussion : A hernia is the “abnormal protrusion of an organ or part of an organ out of the cavity in which it is normally contained” (Ahuja 2007). Since there was peristalsis visualized, it can be proved that the anechoic area with hyperechoic wall is bowel. The Color Doppler proved that the bowel was still alive and had not been strangulated.

Two differential diagnoses for this patient would be appendicitis and stretching of the round ligament. Appendicitis occurs on the right side, but is typically associated with rebound pain. Stretching of the round ligament occurs with pregnancy as the uterus grows, causing sharp pains, but does not cause a palpable bump to form.

Reference
Ahuja A. Diagnostic imaging: ultrasound. Salt Lake City, UT: Amirsys, Inc. 2007.