Transverse
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JOHN
Colon V.
in Adult
FORREST1
2
AND
Umbilical
ROBERT
Hernia
J. STANLEY1
The transverse colon may extend Into an umbilical or other ventral hernia. An unusual configuration, extra anterior loops, outpouchings , narrowing , or nonmalignant-appearing obstruction in the involved segment of the colon should suggest possible herniation. Clinical or radiographic confirmation is easily accomplished. Five cases are presented to illustrate some of the deformities of the transverse colon due to involvement in an umbilical hernia. Introduction
The recognition of external hernias, including inguinal, femonal, umbilical and other forms of ventral hernias, is rarely a radiologic problem. Occasionally a patient with an obvious inguinal hernia will have portions of the colon or small bowel within the hernial sac. The radiographic find ings are usually straightforward However, the alterations in the configuration and position of the transverse colon due to involvement in an umbilical hernia may be confusing. Areas of partial obstruction, a twist, an extra anterior loop, on a knuckle of colon wall resembling a sacculation or pseudodiverticulum may suggest a cause other than simple henniation. The barium enema findings in various ventral hernias have been infrequently alluded to in the past [1 2] and are only briefly described in more current texts of gastrointestinal radiology [3]. This paper presents five patients who illustrate some of the deformities of the transverse colon due to involvement in an umbilical hernia. .
V
Fig. 1.-Case 1 . Posteroantenior film showing unusual lobulation in midportion of transverse colon (arrows). At fluoroscopy, this disappeared with reduction of small Richter’s type umbilical hernia. Patient also had
,
a cecal carcinoma.
showed
Case Case Case
Reports
1
Case
B. B., an 84-year-old disease
after
woman,
a Billroth
had recurrent II procedure.
symptoms
A small
umbilical
of
5 woman,
had low
back
pain
and
anemia.
Discussion
Umbilical hernias in adults are most often seen in obese middle-aged on elderly multiparous women, as was the case in the five patients presented here. Increased pressure on the abdominal wall associated with pregnancy and obesity causes henniation through naturally weak areas, such as the umbilicus [4]. The associa-
,
tion
of pregnancy
hernias,
including
and
obesity
epigastnic
Received March 22, 1977; accepted after revision September 13, 1977. I Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri 63110. 2 Present address: Department of Radiology, University of California and Veterans Administration Hospital, California 92161 . Address reprint requests to J. V. Forrest. 130 :57-59, January 1978 Roentgen Ray Society
much repaired.
of
D. J. a 60-year-old obese woman, was admitted for elective hernia repair. A small umbilical hernia was repaired 4 years earlier at the time of jejunoileal bypass surgery. Barium study
C 1978 American
containing
was surgically
4
umbilical
3
Am J Roentgenol
hernia
3). The hernia
A large umbilical hernia repaired surgically 23 years earlier had obviously recurred (fig. 5). At surgery, a partially obstructed segment of the mid-transverse colon incarcerated in the hernia was reduced and the hernia repaired.
hernia was noted clinically. A barium examination performed to evaluate abdominal pain demonstrated a small reducible umbilcal hernia (fig. 2). Treatment of the asymptomatic umbilical hernia was not felt to be necessary. Case
(fig.
M. C., a 67-year-old
2
peptic
recurrent colon
N. T., a markedly obese 53-year-old woman, had crampy abdominal pain and a huge umbilical hernia (fig. 4). At surgery the transverse colon was incarcerated in the hernia.
A. L., a 62-year-old obese woman, had diffuse abdominal pain, diarrhea, and vomiting. An umbilical hernia was noted on inspection of the abdomen. Barium enema examination showed a large carcinoma of the cecum and a small Richter’s type umbilical hernia (fig. 1). A right hemicolectomy and hernia repair were done. Case
a large
the transverse
57
with
and
other
types
spigelian,
3350 La Jolla Village
0361 -803X/78/01
of ventral
is not
as
Drive, San Diego,
00-0057
$02.00
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58
Fig. 3.-Case 3. A, Anteroposterior obstruction where colon enters and neck of hernia (arrows).
FORREST
AND
STANLEY
film showing long segment of mid-transverse leaves hernia sac (arrows). B, Cross-table lateral
clear. While none of the other types of ventral hernias are illustrated here, presumably they could produce similar findings on barium study. Small umbilical hernias usually contain only omentum. Transverse colon often enters the larger ones, and occasionally these larger umbilical hernias will contain small bowel, particularly if they are relatively low on the anterior abdominal wall [4]. Small asymptomatic umbilical hernias may have a knuckle of transverse colon in
the with
view
sac.
colon in large umbilical confirming site of hernia
A single
outpouching
an appearance
similar
hernia. Note and showing
of one
wall
Richter’s outpouching
hernia
views
in an
fail
of the
of the
colon
to a pseudodiverticulum
be seen on fluoroscopy and standard films (fig. 1). Cases 1 and 2 represent or oblique
narrowing without slight narrowing at
umbilical
to clarify mid-transverse
location.
the
nature colon,
lateral film will document the umbilical The hernia can also be confirmed during
may
barium enema examples of When
frontal
of an unusual a cross-table
hernia (fig. fluoroscopy
2). by
Downloaded from www.ajronline.org by 190.221.247.225 on 10/17/15 from IP address 190.221.247.225. Copyright ARRS. For personal use only; all rights reserved
COLON
INVOLVEMENT
IN UMBILICAL
HERNIA
Fig. 5.-Case showing
ing as
Fig. 4.-Case
4. Oblique view showing Huge umbilical hernia with was found at surgery.
loop of colon.
anterior
position
incarcerated
colon
it
dilated
leaves hernia
decubitus
portion (arrows).
film from air contrast
of transverse
colon
with
barium
tapered
study narrow-
of dilated
segment
existence prior
localization and manipulation of the palpable hernia with a gloved hand. Long segments of the transverse colon can extend into larger umbilical hernias (fig. 3) and may become incarcerated on obstructed A large loop of transverse colon extending anteriorly on oblique films may be the radiographic clue to a huge umbilical hernia (fig. 4). Partial on complete obstruction has a tapered appearance with smooth margins and intact mucosa (fig. 5). Findings are similar to those seen in other hernias and sometimes with adhesions [5]. When unusual configurations of the transverse colon are encountered, herniations should be considered. The .
5. Lateral
slightly
59
of a hernia to
needed to used if that
the
study,
may not be known and
the
to the radiologist
appropriate
clarify the nature of the diagnosis is not considered.
lesion
maneuvers
will
not
be
REFERENCES
1 . Pendergrass AC: Extrinsic deformities of the colon. Radio!ogy 51 :320-324, 1948 2. Read AC: Observations on the etiology of spigelian hernia. AnnSurg 152:1004-1009, 1960 3. Frimann-Dahl J: Roentgen Examinations in Acute Abdomina! Diseases. Springfield, Ill., Thomas, 1974 4. Gibson LD, Gaspar MA: A review of 606 cases of umbilical hernia. Surg Gyneco! Obstet 109:313-322, 1959 5. Kyaw MM, Koehler PR: Pseudotumors of colon due to adhesions. Radiology 103:597-599, 1972
Downloaded from www.ajronline.org by 190.221.247.225 on 10/17/15 from IP address 190.221.247.225. Copyright ARRS. For personal use only; all rights reserved
JOHN
Colon V.
in Adult
FORREST1
2
AND
Umbilical
ROBERT
Hernia
J. STANLEY1
The transverse colon may extend Into an umbilical or other ventral hernia. An unusual configuration, extra anterior loops, outpouchings , narrowing , or nonmalignant-appearing obstruction in the involved segment of the colon should suggest possible herniation. Clinical or radiographic confirmation is easily accomplished. Five cases are presented to illustrate some of the deformities of the transverse colon due to involvement in an umbilical hernia. Introduction
The recognition of external hernias, including inguinal, femonal, umbilical and other forms of ventral hernias, is rarely a radiologic problem. Occasionally a patient with an obvious inguinal hernia will have portions of the colon or small bowel within the hernial sac. The radiographic find ings are usually straightforward However, the alterations in the configuration and position of the transverse colon due to involvement in an umbilical hernia may be confusing. Areas of partial obstruction, a twist, an extra anterior loop, on a knuckle of colon wall resembling a sacculation or pseudodiverticulum may suggest a cause other than simple henniation. The barium enema findings in various ventral hernias have been infrequently alluded to in the past [1 2] and are only briefly described in more current texts of gastrointestinal radiology [3]. This paper presents five patients who illustrate some of the deformities of the transverse colon due to involvement in an umbilical hernia. .
V
Fig. 1.-Case 1 . Posteroantenior film showing unusual lobulation in midportion of transverse colon (arrows). At fluoroscopy, this disappeared with reduction of small Richter’s type umbilical hernia. Patient also had
,
a cecal carcinoma.
showed
Case Case Case
Reports
1
Case
B. B., an 84-year-old disease
after
woman,
a Billroth
had recurrent II procedure.
symptoms
A small
umbilical
of
5 woman,
had low
back
pain
and
anemia.
Discussion
Umbilical hernias in adults are most often seen in obese middle-aged on elderly multiparous women, as was the case in the five patients presented here. Increased pressure on the abdominal wall associated with pregnancy and obesity causes henniation through naturally weak areas, such as the umbilicus [4]. The associa-
,
tion
of pregnancy
hernias,
including
and
obesity
epigastnic
Received March 22, 1977; accepted after revision September 13, 1977. I Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri 63110. 2 Present address: Department of Radiology, University of California and Veterans Administration Hospital, California 92161 . Address reprint requests to J. V. Forrest. 130 :57-59, January 1978 Roentgen Ray Society
much repaired.
of
D. J. a 60-year-old obese woman, was admitted for elective hernia repair. A small umbilical hernia was repaired 4 years earlier at the time of jejunoileal bypass surgery. Barium study
C 1978 American
containing
was surgically
4
umbilical
3
Am J Roentgenol
hernia
3). The hernia
A large umbilical hernia repaired surgically 23 years earlier had obviously recurred (fig. 5). At surgery, a partially obstructed segment of the mid-transverse colon incarcerated in the hernia was reduced and the hernia repaired.
hernia was noted clinically. A barium examination performed to evaluate abdominal pain demonstrated a small reducible umbilcal hernia (fig. 2). Treatment of the asymptomatic umbilical hernia was not felt to be necessary. Case
(fig.
M. C., a 67-year-old
2
peptic
recurrent colon
N. T., a markedly obese 53-year-old woman, had crampy abdominal pain and a huge umbilical hernia (fig. 4). At surgery the transverse colon was incarcerated in the hernia.
A. L., a 62-year-old obese woman, had diffuse abdominal pain, diarrhea, and vomiting. An umbilical hernia was noted on inspection of the abdomen. Barium enema examination showed a large carcinoma of the cecum and a small Richter’s type umbilical hernia (fig. 1). A right hemicolectomy and hernia repair were done. Case
a large
the transverse
57
with
and
other
types
spigelian,
3350 La Jolla Village
0361 -803X/78/01
of ventral
is not
as
Drive, San Diego,
00-0057
$02.00
Downloaded from www.ajronline.org by 190.221.247.225 on 10/17/15 from IP address 190.221.247.225. Copyright ARRS. For personal use only; all rights reserved
58
Fig. 3.-Case 3. A, Anteroposterior obstruction where colon enters and neck of hernia (arrows).
FORREST
AND
STANLEY
film showing long segment of mid-transverse leaves hernia sac (arrows). B, Cross-table lateral
clear. While none of the other types of ventral hernias are illustrated here, presumably they could produce similar findings on barium study. Small umbilical hernias usually contain only omentum. Transverse colon often enters the larger ones, and occasionally these larger umbilical hernias will contain small bowel, particularly if they are relatively low on the anterior abdominal wall [4]. Small asymptomatic umbilical hernias may have a knuckle of transverse colon in
the with
view
sac.
colon in large umbilical confirming site of hernia
A single
outpouching
an appearance
similar
hernia. Note and showing
of one
wall
Richter’s outpouching
hernia
views
in an
fail
of the
of the
colon
to a pseudodiverticulum
be seen on fluoroscopy and standard films (fig. 1). Cases 1 and 2 represent or oblique
narrowing without slight narrowing at
umbilical
to clarify mid-transverse
location.
the
nature colon,
lateral film will document the umbilical The hernia can also be confirmed during
may
barium enema examples of When
frontal
of an unusual a cross-table
hernia (fig. fluoroscopy
2). by
Downloaded from www.ajronline.org by 190.221.247.225 on 10/17/15 from IP address 190.221.247.225. Copyright ARRS. For personal use only; all rights reserved
COLON
INVOLVEMENT
IN UMBILICAL
HERNIA
Fig. 5.-Case showing
ing as
Fig. 4.-Case
4. Oblique view showing Huge umbilical hernia with was found at surgery.
loop of colon.
anterior
position
incarcerated
colon
it
dilated
leaves hernia
decubitus
portion (arrows).
film from air contrast
of transverse
colon
with
barium
tapered
study narrow-
of dilated
segment
existence prior
localization and manipulation of the palpable hernia with a gloved hand. Long segments of the transverse colon can extend into larger umbilical hernias (fig. 3) and may become incarcerated on obstructed A large loop of transverse colon extending anteriorly on oblique films may be the radiographic clue to a huge umbilical hernia (fig. 4). Partial on complete obstruction has a tapered appearance with smooth margins and intact mucosa (fig. 5). Findings are similar to those seen in other hernias and sometimes with adhesions [5]. When unusual configurations of the transverse colon are encountered, herniations should be considered. The .
5. Lateral
slightly
59
of a hernia to
needed to used if that
the
study,
may not be known and
the
to the radiologist
appropriate
clarify the nature of the diagnosis is not considered.
lesion
maneuvers
will
not
be
REFERENCES
1 . Pendergrass AC: Extrinsic deformities of the colon. Radio!ogy 51 :320-324, 1948 2. Read AC: Observations on the etiology of spigelian hernia. AnnSurg 152:1004-1009, 1960 3. Frimann-Dahl J: Roentgen Examinations in Acute Abdomina! Diseases. Springfield, Ill., Thomas, 1974 4. Gibson LD, Gaspar MA: A review of 606 cases of umbilical hernia. Surg Gyneco! Obstet 109:313-322, 1959 5. Kyaw MM, Koehler PR: Pseudotumors of colon due to adhesions. Radiology 103:597-599, 1972
