Incarcerated inguinal hernia presenting as spontaneous scrotal fecal fistula

Spontaneous Enterocutaneous Fistula

Spontaneous scrotal enterocutaneous fistulas (ECFs) are rare and more common in countries with poor access to medical care. Our patients represent the first two reported adult cases of scrotal ECFs in the United States. Both patients were 83-year-old males who presented from assisted living facilities with past medical histories of prostate cancer. The first patient had an ECF from his cecum to right scrotum and the second patient had an ECF from his sigmoid colon to left scrotum. These are the first recorded cases describing spontaneous scrotal ECFs in adults in the United States. They are also the seventh and eighth reported cases worldwide. Both patients had delayed presentations of their incarcerated hernias because their scrotal ECFs decompressed their incarcerated bowels and attenuated the development of obstructive symptoms. Each patient underwent a successful orchiectomy by urology and bowel resection with ligation of their scrotal ECFs, and herniorrhaphy by general surgery.

Fecal Scrotal Abscess Secondary to Spontaneous Retroperitoneal Perforation of Ascending Colon

Introduction

Fecal abscess or enterocutaneous fistulas of the scrotum are rare and are invariably the result of incarcerated bowel loop in inguinal hernia. Spontaneous perforation of the colon (SPC) having no definite cause is also rare. Much rarer is posterior colonic perforations causing an extensively large retroperitoneal abscess. Similarly, spread of retroperitoneal abscess to the thigh or scrotum has rarely been reported. We report a case of spontaneous posterior perforation of ascending colon resulting in large retroperitoneal abscess eventually causing scrotal abscess, which resolved on conservative treatment and drainage of the scrotal fecal abscess. Case Presentation. A 20-year-old male presented with gradually increasing noncolicky pain right side abdomen with nonprojectile vomiting, obstipation, and progressive abdominal distension. Clinically, the abdomen was tender with guarding over the right side with signs of inflammation on the right side back with no associated hernia. On conservative treatment, he was gradually improved but developed right side scrotal abscess a week later. CT abdomen showed a large retroperitoneal collection having multiple internal air lucencies, displacing ascending colon and caecum medically with discontinuity in the posterior wall of ascending colon. The large retroperitoneal collection was extending from right pararenal and posterior perihepatic soft tissue planes to the right iliac fossa and thigh. On drainage of the scrotal abscess, about 350 ml of fecal contents was evacuated. The patient gradually recovered and was discharged on conservative treatment with an uneventful 4-year follow-up.

Conclusion

Diagnosis of retroperitoneal perforation of the colon is often delayed due to the absence of peritoneal irritation. An extensively large retroperitoneal abscess may spread the infection to the scrotum and thigh due to extreme pressure, possibly by dissecting away the transversalis fascia through a deep ring along the side of the spermatic cord. Timely performed CT/MRI can avoid delay in the diagnosis of retroperitoneal abscess and further spread of infection.

Uncommon trans-iliac bone faecal fistula in a leukaemic patient

This is a rare case of an elderly woman diagnosed with acute myeloid leukaemia secondary to myelodysplastic syndrome who presented a spontaneous trans-iliac bone faecal fistula probably related to an incarcerated inguinal hernia and neutropaenia. As far as we know, this is the first described case of a trans-iliac bone faecal fistula.

Spontaneous Enterocutaneous Fistula Resulting from Richter's Hernia

Richter's hernia is due to the entrapment of a part of circumference of the bowel wall. As the bowel continuity is maintained, the patients usually do not have intestinal obstruction. Some patients with Richter's hernia may present with enterocutaneous fistula either spontaneous or due to surgical intervention mistaking the obstructed hernia to be inguinal abscess. This is more so in developing countries due to lack of awareness among the masses or due to the delay in seeking medical attention. Presenting here is a case of a 53-year-old male patient with enterocutaneous fistula which occurred spontaneously and sought medical attention only after about three years of repeated discharge of yellowish fluid from the left inguinal region. Magnetic resonance fistulogram confirmed the diagnosis of enterocutaneous fistula. Laparotomy with resection and primary anastomosis of the fistulous bowel was done. Patient recovered uneventfully without any complications or recurrence.

A rare case of spontaneous inguinal faecal fistula as a complication of incarcerated Richter's hernia with brief review of literature

BACKGROUND

Richter's hernia has an early misleading presentation with tendency to strangulation due to common lack of obstructive symptoms which may lead to delay in diagnosis and hence increased mortality. Rarely inguinal Richter's hernia may present with an uncommon complication of spontaneous fistula. The development of spontaneous faecal fistula secondary to incarcerated inguinal hernias is much rarer among the adult population as compared to the paediatric age group. Most of these fistula have been reported from developing countries like India and Nigeria and is usually the result of poverty, lack of knowledge, neglect, late presentation and lack of proper management.

CASE PRESENTATION

A 62 years old male presented with chief complaints of multiple openings with faecal discharge in the right groin for last 20 days with no history of constipation, trauma, and urinary or other abdominal complaints. CT scan revealed a small gut loop communicating with anterior abdominal wall. Exploratory laparotomy revealed a loop of distal ileum adherent to the internal inguinal ring which was retrieved back into the abdominal cavity. There was perforation over the loop. Resection of the segment of ileum involved was done with ileo-ileal hand sewn anastomosis and the internal inguinal ring was closed from inside of the peritoneal cavity. The openings in the skin over the inguinal region were communicated with each other and laid open due to cellulitis of the area involved and pus discharge.

CONCLUSION

Spontaneous faecal fistula in inguinal region following rupture of strangulated Richter's hernia especially in adults is very rare and can occur even in absence of obstructive symptoms. In presentation of any groin swelling, there is need for an early accurate diagnosis followed by prompt treatment. The delay in its diagnosis and management may result in this rare complication of spontaneous faecal fistula. This reflects the state of health care in the developing world and needs to be addressed by the concerned authorities.

An Incarcerated Colon Inguinal Hernia That Perforated into the Scrotum and Exhibited an Air-Fluid Level

There are few reports of a transverse colon inguinal hernia; furthermore, an inguinal hernia perforating the scrotum is rare. Here we report the case of a 79-year-old man who died after developing an incarcerated colon inguinal hernia that perforated the scrotum and exhibited an air-fluid level. The patient was referred to our hospital in November 2011 with a complaint of inability to move. Physical examination revealed an abnormally enlarged left scrotum and cold extremities. He reported a history of gastric cancer that was surgically treated more than 30 years ago. His white blood cell count and C-reactive protein level were elevated. Abdominal and inguinal computed tomography revealed that his transverse colon was incarcerated in the left inguinal canal. Free air and air-fluid level were observed around the transverse colon, suggestive of a perforation. The patient and his family refused any surgical intervention; therefore, he was treated with sultamicillin tosilate hydrate and cefotiam hydrochloride. However, he succumbed to panperitonitis 19 days after admission. The findings from this case indicate that the transverse colon can perforate into an inguinal hernia sac.

Scrotal enterocutaneous fistula: a rare initial presentation of inguinal hernia

We describe the case of a 70-year-old man with a long history of inguinal hernia who finally presented to the emergency department with a scrotal enterocutaneous fistula. This is a rare complication of an incarcerated/obstructed direct inguinal hernia. We performed exploratory laparotomy with resection of the perforated small bowel and end-to-end anastamosis of the ileal segment using the purse-string suture at the deep inguinal ring.