Scrotal enterocutaneous fistula: a rare initial presentation of inguinal hernia

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.

Spontaneous groin enterocutaneous fistula following neglected inguinal hernia in 3-month infant spontaneous enterocutaneous fistula following neglected inguinal hernia leading to groin enterocutaneous fistula in 3-month infant

Hernia is defined as a protrusion of part or whole of a viscera through an abnormal opening in the wall of the cavity containing the viscera. Strangulation of the viscera within the hernial sac is a common complication in our environment, and this occurs in both adult and children. We study the presentation and management of a 3-month-old infant with groin enterocutaneous fistula following a neglected inguinal hernia. A 3-month-old infant presented late with perforated intestine in an inguinal hernia and managed by the resection and anastomosis of the small intestine. The outcome of a neglected inguinal hernia is still poor in our environment.

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.

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.

Spontaneous entero-labial fistula complicating Richters hernia: Report of a case

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Spontaneous entero-labial fistula complicating Richters hernia occurring in an adult female is rare in Africa.

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Spontaneous faecal fistula in inguinal region following rupture of strangulated Richter’s hernia especially in female adults is uncommon.

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It can occur even in absence of obstructive symptoms

Background

Richter's hernia is defined as a type of hernia in which only part of the circumference of the antimesenteric border of a bowel wall is incarcerated within the hernia sac leading to ischemia, gangrene and perforation of the hollow viscus. Richter's hernia is known to cause strangulation without obstruction due to involvement of only a part of the circumference of a bowel wall. Inguino-labial Richter's hernia presenting with the complication of spontaneous entero-cutaneous fistula is rare.

Aim

This is to report a case of spontaneous entero-labial fistula complicating Richters hernia occurring in an adult female.

Case report

A 61-year-old woman presented with a history of sudden generalized abdominal pain. She had a prior history left inguino-labial swelling of six years duration, which was initially reducible but became irreducible two weeks prior to presentation. There was associated discharge from the swelling a few days later. She was pale and febrile. Her temperature was 39.2 °C, pulse rate was 110 per minute and blood pressure was 130/60 mmHg. A diagnosis of left inguinolabial hernia was made.

She was resuscitated and an exploration of the groin swelling was made. A rupture of the anti-mesenteric border of the ileum with strangulated preperitoneal fat was found. She had resection and anastomosis of the ileum.

Conclusion

Spontaneous faecal fistula in inguinal region following rupture of strangulated Richter's hernia especially in adults is uncommon 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.

Inguinal enterocutaneous fistula in a dog

A two-year-old Jack Russell terrier presented with a chronic history of weight loss and the recent development of a discharging wound in the left inguinal region that was confirmed by ultrasound and contrast radiography to be an enterocutaneous fistula. One day following admission the dog displayed signs of abdominal pain and the general condition deteriorated. At exploratory coeliotomy there was evidence of septic peritonitis and a segment of jejunum was found firmly adhered to the left inguinal canal. The affected jejunal segment was excised and an end-to-end anastomosis performed. A penrose drain was placed in the inguinal wound which was subsequently managed with open drainage. The inguinal wound healed successfully by second intention and the dog returned to normal body condition. The left testis became atrophic and castration was performed several weeks later. To the authors' knowledge this is the first veterinary case report of an inguinal enterocutaneous fistula.

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.