Amyrand’s Hernia

A 56-year-old man presents to the emergency department via ambulance with a chief complaint of vomiting. The patient reports throwing up coffee ground emesis for the past 2 days. The patient denies abdominal pain, fever, chills, and change in bowel habits. Past medical history includes severe gout, cardiomyopathy, chronic renal failure, hypertension, sickle cell trait, and pacemaker insertion. 

On physical exam, the patient appears well nourished, well developed and in no acute distress. The patient is afebrile and vital signs are within normal limits. The abdomen is soft, with no tenderness or guarding, and normal bowel sounds are heard. An extremely large inguinal hernia is observed. 

Lab work includes a white blood cell count of 25.6 K/µL, hemoglobin of 7.1, and a hematocrit of 21.7%. An abdominal and pelvic CT scan reveal an extremely large bilateral inguinal hernia containing both small and large bowel and a moderate amount of fluid. The right inguinal hernia contains a normal appearing appendix (Figure). The small bowel appears diffusely dilated and there is a small segment of narrowing of the small bowel as it enters the right inguinal hernia.

The presence of a vermiform appendix in an inguinal hernia sac that is either non-inflamed, inflamed, or perforated is known as an Amyand’s hernia.¹ The incidence of a non-inflamed appendix in an inguinal hernia is estimated at 1%, versus that of the presence of appendicitis in the inguinal hernia at 0.13%.² The use of CT scan in diagnosis is often overlooked as presenting symptoms may lead to the premature diagnosis of an incarcerated or strangulated hernia, whereby the patient is sent directly to surgery. 

A CT scan aids not only in the diagnosis, but also the treatment. Although debated, current practice recommends leaving a non-inflamed appendix intact and performing an appendectomy for the inflamed or perforated appendix.¹ ■

References:

1. Sharma H, Gupta A, Shekhawat NS, et al. Amyand’s hernia: a report of 18 consecutive patients over a 15-year period. Hernia. 2007;11(1):31-35.

2.House MG, Goldin SB, Chen H. Perforated Amyand’s hernia. South Med J. 2001;94(5):496-498.