RADIOLOGY CASE

Nausea, vomiting, and lower abdominal pain

ROBERT M. BRANSTETTER III, MD

A 77-year-old woman presented to the emergency depart-

ment because of nausea, vomiting, and lower abdominal
pain for 2 days. Physical examination revealed an elderly, cachetic
female with abdominal distension. Computed tomography (CT)
images are shown below (Figures 1–4).
For diagnosis and discussion, see the following page.

➜
➜

➜
➜

Figure 1. CT image demonstrates a segment of markedly dilated small bowel Figure 2. CT image again shows markedly dilated small bowel and a segment of
(arrow). This image is 1.5 cm superior to the image in Figure 2. collapsed small bowel (arrows). The transition from dilated small bowel to col-
lapsed small bowel establishes the diagnosis of small-bowel obstruction.

Figure 3. CT image demonstrates (along with Figure 4) the etiology of the small- Figure 4. CT image demonstrating (along with Figure 3) the etiology of the small-
bowel obstruction. bowel obstruction. Can you make the correct diagnosis?

From the Department of Radiology, Baylor University Medical Center, Dallas, Texas.
Corresponding author: Robert M. Branstetter III, MD, Department of Radiology,
Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas 75246.

BUMC PROCEEDINGS 2000;13:177–178 177

DIAGNOSIS: Incarcerated obturator hernia producing small-bowel
obstruction.

DISCUSSION
Obturator hernias are a rare cause of small-bowel obstruction,

accounting for approximately 0.4% of all cases (1). Despite ad-
vances in modern medicine, the mortality rate of small-bowel
obstructions secondary to obturator hernias remains high because
of vague presenting symptoms, which make the diagnosis diffi-
cult at initial presentation and may delay treatment.
Obturator hernia is one of several types of abdominal wall
hernias. Other types include incisional, umbilical, spigelian, lum-
bar, and epigastric hernias.
The most common abdominal wall hernia is the incisional
hernia, which occurs at sites of previous abdominal incisions.
These occur in up to 14% of patients with a history of abdomi-
nal surgery (2).
Unlike incisional hernias, umbilical hernias are predomi-
nantly congenital. These hernias occur more commonly in blacks,
and most will spontaneously resolve by the age of 2 years. Patients
with large amounts of ascites may also develop umbilical hernias.
Spigelian hernias project through the spigelian fascia, which
is located at the lateral edge of the rectus abdominis muscles.
Lumbar, or dorsal, hernias protrude through the posterior
abdominal wall. The most common location for these hernias is
the superior lumbar triangle (Grynfeltt’s), which is located im-
mediately inferior to the 12th rib. The second most common
location for lumbar or dorsal hernias is in the inferior lumbar
triangle (Petit’s) (3).
Epigastric hernias are produced by a defect in the linea alba
at a level between the xiphoid process and the umbilicus. These
hernias are more common in men (2).
Obturator hernias occur predominantly in the seventh and
eighth decades of life and are 9 times more frequent in women
than men (4). Large, wide pelvic bones and more horizontally
oriented obturator canals, which are prevalent in women, are
believed to predispose to the development of obturator hernias
(5). The typical patient with an obturator hernia is a thin, eld-
erly female. Contributing factors are prior pregnancy, chronic ill-
ness, malnutrition, and any condition that produces peritoneal
weakening.
Obturator hernias protrude through the obturator foramina,
which are located in the anterolateral pelvic wall bilaterally
immediately inferior to the acetabula (Figure 5). The obturator
foramina are covered by the obturator membranes, except antero-
superiorly where the obturator canals are located. The obtura-
tor nerve and associated blood vessels are located in this canal
and are surrounded by fatty tissue. Severe weight loss, aging, and
malnutrition contribute to a loss of the surrounding fatty tissue,
creating a space around the obturator nerve and vessels and pre-
disposing to the development of an obturator hernia (4).
The most common symptom of obturator hernia is small-
bowel obstruction (Figure 6), which produces varied clinical
symptoms. Frequently, the initial symptom is mild, intermittent
abdominal pain, which is secondary to intermittent, incomplete
small-bowel obstruction. Related physical findings are rare since
the incarcerated hernia is located posterior to the pectineus and
adductor longus muscles (5). The Howship-Romberg sign, which
➜
➜
Figure 5. CT image (detail of Figure 3) shows small bowel (arrows) entering the
obturator foramen.
➜
Figure 6. CT image (detail of Figure 4 ) demonstrates incarcerated small bowel (ar-
row) herniated between the pectineus muscle and the external obturator muscles.
is suggestive of an obturator hernia, consists of pain along the
medial aspect of the thigh, extending to the knee, caused by ir-
ritation of the obturator nerve. However, this sign is present in
only approximately 50% of cases of obturator hernia (4).
Because of such nonspecific presenting signs and symptoms,
CT plays an important role in the diagnosis of obturator hernia
by demonstrating incarcerated small bowel posterior to the
pectineus muscle (Figures 5 and 6). In a recent study, CT pro-
vided an accurate preoperative diagnosis in 11 of 14 patients with
obturator hernia (6). CT is noninvasive and rapidly performed
and can lead to prompt diagnosis and treatment. Early treatment,
which usually consists of laparotomy and repair of the hernia
defect, is important to prevent incarceration, strangulation, and
perforation, which are associated with high mortality rates.
1. Bergstein JM, Condon RE. Obturator hernia: current diagnosis and treat-
ment. Surgery 1996;199:133–136.
2. Molmenti EP, Doherty GM. Hernias. In Doherty GM, Bauman DS, Creswell
LL, Goss JA, Lairmore TC, eds. Washington Manual of Surgery. Boston: Little
Brown Publishers, 1999:427–433.
3. Kortz WJ, Sabiston DC Jr. Hernias. In Sabiston DC Jr, ed. Sabiston’s Essen-
tials of Surgery. Philadelphia: WB Saunders Co, 1987:639–654.
4. Hsu CH, Wang CC, Jeng LB, Chen MF. Obturator hernia: a report of eight
cases. Am Surg 1993;59:709–711.
5. Ijiri R, Kanamaru H, Yokoyama H, Shirakawa M, Hashimoto H, Yoshino
G. Obturator hernia: the usefulness of computed tomography in diagnosis.
Surgery 1996;119:137–140.
6. Yokoyama Y, Yamaguchi A, Isogai M, Hori A, Kaneoka Y. Thirty-six cases
of obturator hernia: does computed tomography contribute to postoperative
outcome? World J Surg 1999;23:214–216.

178 BAYLOR UNIVERSITY MEDICAL CENTER PROCEEDINGS VOLUME 13, NUMBER 2