Posterior rectus sheath hernia causing intermittent small bowel obstruction

Abstract

A posterior rectus sheath hernia is an abdominal wall hernia that is rarely encountered. Owing to its rarity, it can be easily overlooked in the setting of a patient presenting with abdominal pain. We report a case of a posterior rectus sheath hernia that caused intermittent small bowel obstruction. The unusual aspects of this case are that the defect was large, measuring 6 cm in the transverse diameter, and that it contained small bowel within a large portion of the rectus sheath. Because the defect was large and affected nearly the entire posterior rectus sheath, it was difficult to discern on computed tomography until a small bowel obstruction developed. In this case, a limited awareness of this clinical entity contributed to the delay in diagnosis.

Keywords: CT; abdomen; abdominal pain; hernia; rectus sheath; small bowel obstruction.

Figure 1

51 year old female with a posterior rectus sheath hernia. FINDINGS: Supine abdominal radiograph shows a dilated loop of bowel in the upper abdomen (arrow), a nonspecific finding. TECHNIQUE: Supine abdominal radiograph.

Figure 2

51 year old female with a posterior rectus sheath hernia. FINDINGS: Axial multidetector CT of the abdomen (a), sagittal reconstruction (b), and magnified axial view (c) with intravenous and oral contrast show multiple dilated loops of small bowel consistent with a small bowel obstruction. In retrospect, these small bowel loops extend through a large defect in the posterior rectus sheath (arrows). TECHNIQUE: GE Lightspeed VCT. Axial CT with sagittal reconstruction, 654 mA, 120 kV, 5 mm axial mm slices, 3 mm sagittal reconstructions, Oral contrast-Omnipaque 240 50 ml + 850 ml water, IV contrast-Isovue-370 100 ml

Figure 3

51 year old female with a posterior rectus sheath hernia. FINDINGS: Axial multidetector CT of the abdomen (a), sagittal reconstruction (b), and magnified axial view (c) with intravenous contrast only were read as normal. In retrospect, a large posterior rectus sheath defect contains multiple loops of small bowel (arrows) although no small bowel obstruction is present. TECHNIQUE: GE Lightspeed VCT. Axial CT with sagittal reconstruction, 704 mA, 120 kV, 3 mm axial slices, 5 mm sagittal reconstructions, Oral contrast-none, IV contrast-Isovue-370 100 ml.

Figure 4

51 year old female with a posterior rectus sheath hernia. FINDINGS: Axial multidetector CT of the abdomen (a), sagittal reconstruction (b), and magnified axial view (c) with intravenous and oral contrast show multiple dilated loops of small bowel consistent with a small bowel obstruction. The small bowel loops herniate through a large defect in the posterior rectus sheath fascia and abut the anterior abdominal wall (arrows). TECHNIQUE: GE Lightspeed VCT. Axial CT with sagittal reconstruction, 654 mA, 120 kV, 3 mm axial slices, 5 mm sagittal reconstructions, Oral contrast-Omnipaque 240 50 ml + 850 ml water, IV contrast-Isovue-370 100 ml.