DOI: 10.1148/rg.263055714
RadioGraphics 2006;26:691-699
© RSNA, 2006
Anterior Abdominal Wall Hernias: Findings in Barium Studies1
Hanna M. Zafar, MD,
Marc S. Levine, MD,
Stephen E. Rubesin, MD and
Igor Laufer, MD
1 From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Received July 7, 2005; revision requested September 7 and received September 21; accepted September 22. All authors have no financial relationships to disclose.
Address correspondence to M.S.L. (e-mail: marc.levine{at}uphs.upenn.edu).
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Abstract
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Findings of anterior abdominal wall hernias at computed tomography and magnetic resonance imaging are well documented; however, little information is available about the depiction and characterization of such hernias in barium studies, primarily in small-bowel follow-through examinations. Such examinations are performed frequently, and radiologists should be familiar with the hernia features that may be observed. Anterior abdominal wall hernias are best recognized in profile on lateral spot images from a small-bowel follow-through study when one or more loops of bowel extend beyond the fascial planes of the anterior abdominal wall, with luminal narrowing at the entry or exit site of the hernia or at both sites. In some patients, the hernia also can be recognized indirectly on a frontal view because of the displacement and, often, extrinsic compression or deformity of herniated bowel loops. In such cases, additional views should be obtained with the patient in the lateral position to confirm the presence of the hernia with direct visualization of the herniated loops in profile. The reducibility of bowel from an anterior abdominal wall hernia also can be assessed with manual palpation of the abdominal wall while the patient is in the lateral position. Manual palpation performed during fluoroscopy helps determine whether the bowel loops can be returned to the proper location or are fixed in the hernia, an important observation because of the higher risk of obstruction or strangulation when the bowel is incarcerated. Fluoroscopy therefore is a useful technique for the detection and characterization of anterior abdominal wall hernias in barium studies.
© RSNA, 2006
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Introduction
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Anterior abdominal wall hernias, also known as ventral hernias, are a leading cause of abdominal surgery in the United States (1). These hernias involve the protrusion of part of the peritoneal sac through a defect in the muscle layers of the anterior abdominal wall. They are classified on the basis of their location or cause. The major types include incisional hernias, parastomal hernias, umbilical or periumbilical hernias, and spigelian hernias. With the increasing frequency of abdominal surgery, incisional hernias have become the most common type of anterior abdominal wall hernia. Incisional hernias occur at sites of weakening along postoperative incisions, usually at the midline (2,3). In our experience, parastomal hernias also are common, as ileostomies and colostomies are frequently performed by the surgical service at our hospital.
Anterior abdominal wall hernias may contain a variety of intraperitoneal structures, including fat, omentum, and bowel. Bowel-containing hernias are particularly important because of potential complications related to incarceration, obstruction, or strangulation of the bowel, which lead to ischemia and infarction (1). The features of anterior abdominal wall hernias at computed tomography (CT) and magnetic resonance imaging are well documented (4–10). However, little information is available about the detection and characterization of such hernias in barium studies, primarily in small-bowel follow-through examinations. The data from a recent survey show that nearly two-thirds of radiology groups perform at least as many barium studies of the small bowel as were performed 5 years ago, and some perform more (11). Radiologists therefore should be familiar with the various features of anterior abdominal wall hernias in barium studies.
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Clinical Findings
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Anterior abdominal wall hernias can be diagnosed on clinical grounds when a physical examination reveals a bulge in the abdominal wall that is visualized or palpated with or without a Valsalva maneuver to increase intra-abdominal pressure (12). Some patients present with abdominal pain or, if the hernia is incarcerated (ie, nonreducible) or strangulated, with signs and symptoms of intestinal obstruction or ischemia, but others have no symptoms that are attributable to a hernia of this type (13). Anterior abdominal wall hernias also can be difficult to detect at physical examination because of obesity or abdominal pain that limits the physician’s ability to palpate the abdomen (14).
As a result, anterior abdominal wall hernias, particularly small hernias in asymptomatic patients, often are not detected because the clinical findings do not evoke suspicion.
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Radiographic Findings
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Detection and Characterization
Because an anterior abdominal wall hernia may be occult in many of those affected, in barium studies the abdomen routinely should be imaged fluoroscopically with the patient in the lateral position, even in the absence of any clinical evidence of hernia, particularly if there is a history of abdominal surgery. Anterior abdominal wall hernias are best depicted in profile on lateral spot images, on which they are evidenced by one or more loops of bowel that extend beyond the fascial planes of the anterior abdominal wall (15,16). In most cases, individual bowel loops can be seen entering and exiting the hernial orifice, with luminal narrowing at the entry and exit sites (Fig 1a). However, some patients may have a large hernia that contains multiple loops of bowel and in which the entering and exiting loops are not narrowed because of the large size of the hernial orifice (Fig 2a).
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Figure 1a. Small anterior abdominal wall hernia in a 42-year-old woman. (a) Right lateral spot image from a small-bowel follow-through examination shows a single small-bowel loop (arrow) anterior to the fascial planes of the anterior abdominal wall. Note the narrowing of the loop where it enters and exits the hernia (arrowheads). (b) Right lateral spot image shows reduction of the hernia with manual palpation. (Arrow indicates a lead glove.)
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Figure 1b. Small anterior abdominal wall hernia in a 42-year-old woman. (a) Right lateral spot image from a small-bowel follow-through examination shows a single small-bowel loop (arrow) anterior to the fascial planes of the anterior abdominal wall. Note the narrowing of the loop where it enters and exits the hernia (arrowheads). (b) Right lateral spot image shows reduction of the hernia with manual palpation. (Arrow indicates a lead glove.)
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Figure 2a. Large anterior abdominal wall hernia in a 56-year-old woman. (a) Right lateral spot image from a small-bowel follow-through examination shows multiple loops of small bowel (arrows) anterior to the fascial planes of the anterior abdominal wall. Note the minimal extrinsic compression of the bowel loops where they enter and exit the large hernial orifice (arrowheads). (b) Right lateral spot image shows reduction of the hernia with manual palpation. (Arrow indicates a lead glove.)
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Figure 2b. Large anterior abdominal wall hernia in a 56-year-old woman. (a) Right lateral spot image from a small-bowel follow-through examination shows multiple loops of small bowel (arrows) anterior to the fascial planes of the anterior abdominal wall. Note the minimal extrinsic compression of the bowel loops where they enter and exit the large hernial orifice (arrowheads). (b) Right lateral spot image shows reduction of the hernia with manual palpation. (Arrow indicates a lead glove.)
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Other patients may have a Richter-type hernia, in which only a portion of the bowel wall circumference enters the hernial sac and appears as a localized outpouching (Figs 3, 4) (8,17). Because the intestinal lumen remains patent, a Richter hernia rarely causes obstruction; however, the affected portion of the bowel may be incarcerated in the hernia, a condition that leads to bowel strangulation and infarction (8,17). Still other patients may have a parastomal hernia, which is best seen in profile on lateral spot images. A parastomal hernia appears as one or more intestinal loops alongside a loop of ileum or colon at the site of the ileostomy or colostomy stoma (Fig 5).
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Figure 3. Richter-type anterior abdominal wall hernia in a 55-year-old woman. Left posterior oblique spot image from a double-contrast barium enema study shows deformation of the anterior wall of the transverse colon (arrow) where it partially enters the hernial sac.
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Figure 4a. Richter-type anterior abdominal wall hernia in a 65-year-old woman. (a) Left posterior oblique spot image from a single-contrast barium enema study shows an outward bulge (arrow) in the inferior aspect of the distal transverse colon. (b) Contrast-enhanced CT scan shows an anterior bulge of the transverse colon in an area of diastasis recti, where the anterior wall of the transverse colon (arrow) enters a small hernial sac located to the left of the midline.
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Figure 4b. Richter-type anterior abdominal wall hernia in a 65-year-old woman. (a) Left posterior oblique spot image from a single-contrast barium enema study shows an outward bulge (arrow) in the inferior aspect of the distal transverse colon. (b) Contrast-enhanced CT scan shows an anterior bulge of the transverse colon in an area of diastasis recti, where the anterior wall of the transverse colon (arrow) enters a small hernial sac located to the left of the midline.
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Figure 5. Parastomal hernia in a 39-year-old woman who previously underwent ileostomy. Right lateral spot image from a small-bowel follow-through examination shows the location of the hernia (large arrow) alongside the distal ileum (small arrow), where the ileum transects the fascial planes of the anterior abdominal wall, at the stoma site. Note the presence of barium in the ileostomy bag.
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In some patients in whom the presence of an anterior abdominal wall hernia is suspected, lateral spot images may fail to show herniated bowel loops beyond the fascial planes of the anterior abdominal wall. In such cases, provocative maneuvers (ie, Valsalva maneuvers) may be performed to increase the intra-abdominal pressure during fluoroscopy; for example, the patient may be instructed to strain or cough. Such maneuvers may cause bowel loops to enter anterior abdominal wall hernias that do not contain bowel on lateral views obtained during normal respiration and thus may facilitate the detection of these hernias (15). Valsalva maneuvers also may cause additional loops of bowel to enter a previously detected hernia (Fig 6).
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Figure 6a. Anterior abdominal wall hernia containing small bowel in a 43-year-old woman. (a) Frontal left posterior oblique spot image from a small-bowel follow-through examination shows lateral and inferior displacement of a small-bowel loop (arrowheads) in the left lower quadrant and extrinsic compression of the bowel (arrows). (b) Right lateral spot image shows a single small-bowel loop (arrowheads) anterior to the abdominal wall. Note the luminal narrowing (arrows) where the bowel enters and exits the hernial orifice. (c) Right lateral spot image during a Valsalva maneuver shows an increased number of small-bowel loops (arrows) in the hernial sac during the application of increased intra-abdominal pressure.
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Figure 6b. Anterior abdominal wall hernia containing small bowel in a 43-year-old woman. (a) Frontal left posterior oblique spot image from a small-bowel follow-through examination shows lateral and inferior displacement of a small-bowel loop (arrowheads) in the left lower quadrant and extrinsic compression of the bowel (arrows). (b) Right lateral spot image shows a single small-bowel loop (arrowheads) anterior to the abdominal wall. Note the luminal narrowing (arrows) where the bowel enters and exits the hernial orifice. (c) Right lateral spot image during a Valsalva maneuver shows an increased number of small-bowel loops (arrows) in the hernial sac during the application of increased intra-abdominal pressure.
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Figure 6c. Anterior abdominal wall hernia containing small bowel in a 43-year-old woman. (a) Frontal left posterior oblique spot image from a small-bowel follow-through examination shows lateral and inferior displacement of a small-bowel loop (arrowheads) in the left lower quadrant and extrinsic compression of the bowel (arrows). (b) Right lateral spot image shows a single small-bowel loop (arrowheads) anterior to the abdominal wall. Note the luminal narrowing (arrows) where the bowel enters and exits the hernial orifice. (c) Right lateral spot image during a Valsalva maneuver shows an increased number of small-bowel loops (arrows) in the hernial sac during the application of increased intra-abdominal pressure.
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Many anterior abdominal wall hernias are not visible on frontal spot images during barium studies. In some patients, however, such hernias may be identified indirectly on frontal or frontal oblique views because of the displacement of the herniated bowel loops, often with extrinsic compression or deformity of the loops where they enter or exit the anterior abdominal wall (Figs 6a, 7a).
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Figure 7a. Anterior abdominal wall hernia containing transverse colon in a 74-year-old woman. (a) Frontal spot image from a single-contrast barium enema study shows a confusing appearance, with a mildly dilated colonic loop (arrows) inferior to the remaining transverse colon. (b) Right lateral spot image from the same study shows a loop of transverse colon (arrows) anterior to the abdominal wall. Note the luminal narrowing (arrowheads) where the bowel enters and exits the hernial orifice. The entering and exiting bowel limbs are superimposed in this view.
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Figure 7b. Anterior abdominal wall hernia containing transverse colon in a 74-year-old woman. (a) Frontal spot image from a single-contrast barium enema study shows a confusing appearance, with a mildly dilated colonic loop (arrows) inferior to the remaining transverse colon. (b) Right lateral spot image from the same study shows a loop of transverse colon (arrows) anterior to the abdominal wall. Note the luminal narrowing (arrowheads) where the bowel enters and exits the hernial orifice. The entering and exiting bowel limbs are superimposed in this view.
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Such findings are suggestive of an abdominal wall hernia even in patients in whom the presence of a hernia is not clinically suspected. In such cases, additional fluoroscopic views should be obtained with the patient in the lateral position, to confirm the presence of a hernia by means of direct visualization of the herniated loops in profile beyond the fascial planes of the anterior abdominal wall (Figs 6b, 7b).
Most bowel-containing anterior abdominal wall hernias are found to harbor loops of small bowel (Figs 1, 2, 5, 6) or, less frequently, colon (Figs 3, 4, 7) or both small bowel and colon. Anterior abdominal wall hernias in the epigastric region occasionally also may contain the antrum or body of the stomach (16,18) (Fig 8). However, gastric involvement in these hernias is uncommon because of the fixed position of the stomach, with its numerous ligamentous attachments, in the upper abdomen (16).
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Figure 8a. Anterior abdominal wall hernia containing gastric antrum in an 85-year-old woman. (a) Lateral spot image from a single-contrast upper gastrointestinal tract series and small-bowel follow-through examination shows the gastric antrum (arrows) in a hernial sac anterior to the fascial planes of the anterior abdominal wall. (b) Contrast-enhanced CT scan shows the portion of the gastric antrum (arrows) within the midline hernia.
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Figure 8b. Anterior abdominal wall hernia containing gastric antrum in an 85-year-old woman. (a) Lateral spot image from a single-contrast upper gastrointestinal tract series and small-bowel follow-through examination shows the gastric antrum (arrows) in a hernial sac anterior to the fascial planes of the anterior abdominal wall. (b) Contrast-enhanced CT scan shows the portion of the gastric antrum (arrows) within the midline hernia.
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Between 18% and 22% of patients with an anterior abdominal wall hernia have multiple hernias (3,19) (Fig 9). We have found as many as five separate anterior abdominal wall hernias in a single patient. The high frequency of multiple hernias underscores the importance of searching for additional hernias when an anterior abdominal wall hernia is found.
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Figure 9. Multiple anterior abdominal wall hernias containing small bowel in a 68-year-old woman. Right lateral spot image from a small-bowel follow-through examination shows four separate hernias that contain small bowel (arrows). All of the hernias arose along a midline abdominal incision.
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Reducibility
Clinicians often assess the reducibility of anterior abdominal wall hernias with a physical examination. This observation has clinical value, as the risk of obstruction or strangulation is greater when the hernial orifice is narrow and bowel is incarcerated in the hernial sac (12).
To our knowledge, however, there is no mention in the literature of the value of fluoroscopy for assessing the reducibility of bowel from these hernias by manual palpation of the abdominal wall with the patient in the lateral position. In our experience, this technique can be used to differentiate reducible hernias from nonreducible hernias while compressing the herniated bowel loops to determine whether they can be returned to the abdomen or are fixed in the hernial sac (Figs 1b, 2b).
Complications
When incarcerated anterior abdominal wall hernias cause intestinal obstruction, barium studies are helpful for documenting the presence of obstruction and identifying its site and cause. In such cases, a small-bowel follow-through examination typically reveals dilated small bowel proximal to the site of entry of the bowel into the hernial orifice, and collapsed small bowel distal to the hernia, with focal narrowing of the small bowel where it enters and exits the hernia (Fig 10). Similarly, a barium enema study may reveal narrowing of the colon where it enters or exits the hernia, with incomplete filling of the dilated colon proximal to the hernia (Fig 11). When colonic obstruction is suspected in these patients, we recommend performing a single-contrast barium enema study rather than a double-contrast barium enema study to show the site and cause of obstruction.
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Figure 10a. Partial small-bowel obstruction due to an incarcerated anterior abdominal wall hernia in a 63-year-old man. (a) Frontal spot image from a small-bowel follow-through examination shows multiple loops of dilated small bowel (arrows) in the lower abdomen and collapsed loops of ileum (arrowheads) more distally. These findings are suggestive of partial small-bowel obstruction, but the site of the obstruction is uncertain. (b) Lateral spot image shows multiple loops of dilated small bowel, with one loop (large arrows) in the hernial sac. Note the focal narrowing of this loop where it enters and exits the hernial orifice (small arrows) and the collapsed small-bowel loop (arrowheads) distal to the hernia. The hernia could not be reduced with manual palpation. These findings indicate a partial small-bowel obstruction due to incarceration. (c) Unenhanced CT scan shows multiple loops of dilated small bowel (arrows), with one loop (arrowheads) entering the anterior abdominal wall hernia. (d) CT scan at an adjacent level shows a collapsed small-bowel loop (arrowheads) where it exits the hernia, as well as several dilated small-bowel loops (arrows) located more proximally.
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Figure 10b. Partial small-bowel obstruction due to an incarcerated anterior abdominal wall hernia in a 63-year-old man. (a) Frontal spot image from a small-bowel follow-through examination shows multiple loops of dilated small bowel (arrows) in the lower abdomen and collapsed loops of ileum (arrowheads) more distally. These findings are suggestive of partial small-bowel obstruction, but the site of the obstruction is uncertain. (b) Lateral spot image shows multiple loops of dilated small bowel, with one loop (large arrows) in the hernial sac. Note the focal narrowing of this loop where it enters and exits the hernial orifice (small arrows) and the collapsed small-bowel loop (arrowheads) distal to the hernia. The hernia could not be reduced with manual palpation. These findings indicate a partial small-bowel obstruction due to incarceration. (c) Unenhanced CT scan shows multiple loops of dilated small bowel (arrows), with one loop (arrowheads) entering the anterior abdominal wall hernia. (d) CT scan at an adjacent level shows a collapsed small-bowel loop (arrowheads) where it exits the hernia, as well as several dilated small-bowel loops (arrows) located more proximally.
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Figure 10c. Partial small-bowel obstruction due to an incarcerated anterior abdominal wall hernia in a 63-year-old man. (a) Frontal spot image from a small-bowel follow-through examination shows multiple loops of dilated small bowel (arrows) in the lower abdomen and collapsed loops of ileum (arrowheads) more distally. These findings are suggestive of partial small-bowel obstruction, but the site of the obstruction is uncertain. (b) Lateral spot image shows multiple loops of dilated small bowel, with one loop (large arrows) in the hernial sac. Note the focal narrowing of this loop where it enters and exits the hernial orifice (small arrows) and the collapsed small-bowel loop (arrowheads) distal to the hernia. The hernia could not be reduced with manual palpation. These findings indicate a partial small-bowel obstruction due to incarceration. (c) Unenhanced CT scan shows multiple loops of dilated small bowel (arrows), with one loop (arrowheads) entering the anterior abdominal wall hernia. (d) CT scan at an adjacent level shows a collapsed small-bowel loop (arrowheads) where it exits the hernia, as well as several dilated small-bowel loops (arrows) located more proximally.
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Figure 10d. Partial small-bowel obstruction due to an incarcerated anterior abdominal wall hernia in a 63-year-old man. (a) Frontal spot image from a small-bowel follow-through examination shows multiple loops of dilated small bowel (arrows) in the lower abdomen and collapsed loops of ileum (arrowheads) more distally. These findings are suggestive of partial small-bowel obstruction, but the site of the obstruction is uncertain. (b) Lateral spot image shows multiple loops of dilated small bowel, with one loop (large arrows) in the hernial sac. Note the focal narrowing of this loop where it enters and exits the hernial orifice (small arrows) and the collapsed small-bowel loop (arrowheads) distal to the hernia. The hernia could not be reduced with manual palpation. These findings indicate a partial small-bowel obstruction due to incarceration. (c) Unenhanced CT scan shows multiple loops of dilated small bowel (arrows), with one loop (arrowheads) entering the anterior abdominal wall hernia. (d) CT scan at an adjacent level shows a collapsed small-bowel loop (arrowheads) where it exits the hernia, as well as several dilated small-bowel loops (arrows) located more proximally.
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Figure 11a. Retrograde colonic obstruction caused by an incarcerated anterior abdominal wall hernia in an 84-year-old woman. (a) Right posterior oblique spot image from a single-contrast barium enema study shows an abrupt transition (arrow) in a middle segment of the transverse colon, with an absence of colonic filling more proximally. (b) Right lateral spot image shows narrowing of the transverse colon (black arrow) where it enters the hernial orifice, a dilated colonic loop (white arrows) in the hernial sac, and complete obstruction (arrowhead) where the colon exits the hernia. This hernia could not be reduced with manual palpation.
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Figure 11b. Retrograde colonic obstruction caused by an incarcerated anterior abdominal wall hernia in an 84-year-old woman. (a) Right posterior oblique spot image from a single-contrast barium enema study shows an abrupt transition (arrow) in a middle segment of the transverse colon, with an absence of colonic filling more proximally. (b) Right lateral spot image shows narrowing of the transverse colon (black arrow) where it enters the hernial orifice, a dilated colonic loop (white arrows) in the hernial sac, and complete obstruction (arrowhead) where the colon exits the hernia. This hernia could not be reduced with manual palpation.
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In patients with an incarcerated bowel-containing anterior abdominal wall hernia, a closed-loop obstruction can lead to strangulation of the bowel, with resultant intestinal ischemia and necrosis. Incarcerated anterior abdominal wall hernias that cause intestinal obstruction also may compromise the vascular supply of the dilated bowel above the site of the obstruction, with resultant ischemia or necrosis in the unincarcerated bowel. In such cases, images from barium studies may reveal thumbprinting, thickened folds, or other signs of small-bowel or colonic ischemia. However, CT is a more sensitive technique for detecting ischemic bowel disease and therefore remains the diagnostic test of choice when the presence of bowel strangulation and ischemia is suspected on clinical grounds in patients with an incarcerated anterior abdominal wall hernia.
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Summary
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Fluoroscopy should be performed with the patient in the lateral position, and, if necessary, lateral spot images should be obtained for the detection of anterior abdominal wall hernias in barium studies, particularly if the patient has a history of abdominal surgery. Most hernias of this type are not clearly visible in frontal or frontal oblique views, although the presence of an anterior abdominal wall hernia is sometimes indirectly indicated on frontal images by displacement and narrowing or deformity of the herniated bowel loops. The reducibility of bowel-containing hernias also can be assessed during the fluoroscopic examination. Fluoroscopy therefore is useful in barium studies for the detection and characterization of anterior abdominal wall hernias.
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Abstract
Introduction
