Key Imaging Findings:

• Large midline anterior abdominal wall hernia (paraumbilical)
• Only mild mesenteric stranding
• ***Key Finding: Hypoenhancing small bowel loops - the small bowel loops in the hernial sac are hypoenhancing -- compare the wall attenuation of the loops in the sac VS other normal small bowel loops.
• NO small bowel obstruction (i.e. if obstructed would see small bowel dilatation proximal to hernia, abrupt transition point at level of hernia, and collapsed bowel distal to this)

Diagnosis: Hernia complicated by Small Bowel Ischemia (Strangulation)

Key learning point: Remember to look for more subtle findings of ischemia, like reduced enhancement. This finding is very frequently missed, but is very important to recognize.

In this case, the patient went to the operating room and the small bowel was dusky / ischemic. After returning it to the abdominal cavity, it pinked up and reversed. Recognizing the finding of ischemia likely saved much of this patient's small bowel.

KEY CONCEPTS TO REVIEW:

• Review the findings of bowel ischemia, covered in a separate case (CT Abdo Course: Part 3, Case 3-4).
• Review complications of hernias - most importantly obstruction and strangulation (ischemia). Remember, incarceration just means it isn't reducible and so is a clinical finding -- and these are at high risk for obstruction or strangulation.