Strangulated epigastric hernia in a 90-year-old man: Point-of-Care Ultrasound (POCUS) as a saving kit: Case report

Abstract

Introduction: The physiological reserve of extreme elderly patients is very limited and has major impact on clinical decisions on their management. Hereby we report a 90-year-old man who presented with a strangulated epigastric hernia and who developed postoperative intra-abdominal bleeding, and highlight the value of Point-of-Care Ultrasound (POCUS) in critical decisions made during the management of this patient.

Presentation of case: A 90-year-old man presented with a tender irreducible epigastric mass. Surgeon-performed POCUS using colour Doppler showed small bowel in the hernia with no flow in the mesentery. Resection anastomosis of an ischaemic small bowel and suture repair of the hernia was performed. Twenty four hours after surgery, in a routine follow up using POCUS, significant intra-peritoneal fluid was detected although the patient was haemodynamically stable. The fluid was tapped under bedside ultrasound guidance and it was frank blood. During induction of anaesthesia for a laparotomy, the patient became hypotensive. Resuscitation under inferior vena cava sonographic measurement, followed by successful damage control surgery with packing, was performed. 36h later, the packs were removed, no active bleeding could be seen and the abdomen was closed without tension. The patient was discharged home 50 days after surgery with good general condition.

Conclusion: POCUS has a central role in the management of critically-ill elderly patients for making quick critical decisions.

Keywords: Critical care; Elderly; Epigastric hernia; Point-of-care; Strangulated; Ultrasound.

Fig. 1

A 90-year-old man presented with a tender irreducible epigastric mass (Fig. 1A). Surgeon performed Point-of-care Ultrasound (Fig. 2B) showed that it was a hernia containing small bowel (SB) which was strangulated because of the narrow neck of the hernia (yellow arrow heads). Colour Doppler showed no flow in the mesentery of the bowel (black arrow).

Fig. 2

Surgical exploration of the hernial sac showed that the strangulated small bowel was dusky, haemorrhagic and not contracting (Fig. 2A). Ten cm of the small bowel was resected and end-to-end anastomosis was performed (Fig. 2B).

Fig. 3

A routine follow Point-of-care Ultrasound by a portable ultrasound machine (Fig. 3A) showed significant intra-peritoneal fluid (F) although the patient was haemodynamically stable. Using a linear probe with a frequency of 10–12 MHz (Fig. 3B), the intra-peritoneal fluid turned out to be heterogeneous. The deep areas of the fluid were more echogenic indicating clotted blood (C). The fluid (F) was tapped under ultrasound guidance (hashed arrow) and it was frank blood.

Fig. 4

Preoperative IVC measurement (82 mm) showed that the patient was hypovolaemic (Fig. 4A). Aggressive resuscitation using crystalloids, blood and fresh frozen plasma was performed under repeated measurement of IVC diameter. IVC increased to 164 mm (Fig. 4B). The patient blood pressure increased from 40/20 mmHg to 110/70 mmHg.