Over the years many amazing cases have been presented during the PEMPix presentation at the American Academy of Pediatrics’ annual national Conference and Exhibition during the Section on Emergency Medicine Sessions. PEMPix Classic is a new featured series on PEMBlog that will highlight some of those classic cases.

The Case

A seven week old full term female presents with swelling of right labia. Parents noted it just a few hours before arrival to the ED. Coincident with the swelling her parents have noted increased fussiness and spitting up. She has been afebrile, with normal urine output and stools. Parents also deny trauma.

On examination she is afebrile, grunting and somewhat sleepy. Her abdomen is firm and tender. She also has notable swelling in her right labia.

An abdominal X-Ray was then obtained…

What is the diagnosis?

A. Non accidental trauma
B. Incarcerated inguinal hernia
C. Infectious lymphadenitis
D. Group A Strep cellulitis with sepsis
E. Rapidly proliferating non-Hodgkin lymphoma

B. Incarcerated inguinal hernia

Of course this is an incarcerated hernia. You will normally see these in boys, but don’t forget they can happen in girls too! Look closely at the X-Ray, and you will see bowel gas in the labial region/down in the pelvis. Urgent surgical exploration found a strangulated ileum with full-thickness necrosis & perforation. Fortunately, post-operative recovery was uneventful.

The incidence is 10 – 20 / 1,000 live births with a male predominance of 6:1. It is most commonly seen in neonates, and incarceration is seen in 6-18%, but as high as 30% of infants < 2mo. Being a former preemie makes them more likely. It is also more likely to be bilateral in ex-preemies, since there was not enough time of the inguinal canal to close.
 
Treatment is manual reduction, with techniques well described online. If you cannot reduce, or you fear strangulation consult surgery immediately.

References

Wang KS, Committee on Fetus and Newborn, American Academy of Pediatrics, Section on Surgery, American Academy of Pediatrics. Assessment and management of inguinal hernia in infants. Pediatrics 2012; 130:768.