A rare case of spontaneous inguinal faecal fistula as a complication of incarcerated Richter’s hernia with brief review of literature

Abstract

BackgroundRichter’s hernia has an early misleading presentation with tendency to strangulation due to common lack of obstructive symptoms which may lead to delay in diagnosis and hence increased mortality. Rarely inguinal Richter’s hernia may present with an uncommon complication of spontaneous fistula. The development of spontaneous faecal fistula secondary to incarcerated inguinal hernias is much rarer among the adult population as compared to the paediatric age group. Most of these fistula have been reported from developing countries like India and Nigeria and is usually the result of poverty, lack of knowledge, neglect, late presentation and lack of proper management.Case presentationA 62 years old male presented with chief complaints of multiple openings with faecal discharge in the right groin for last 20 days with no history of constipation, trauma, and urinary or other abdominal complaints. CT scan revealed a small gut loop communicating with anterior abdominal wall. Exploratory laparotomy revealed a loop of distal ileum adherent to the internal inguinal ring which was retrieved back into the abdominal cavity. There was perforation over the loop. Resection of the segment of ileum involved was done with ileo-ileal hand sewn anastomosis and the internal inguinal ring was closed from inside of the peritoneal cavity. The openings in the skin over the inguinal region were communicated with each other and laid open due to cellulitis of the area involved and pus discharge.ConclusionSpontaneous faecal fistula in inguinal region following rupture of strangulated Richter’s hernia especially in adults is very rare and can occur even in absence of obstructive symptoms. In presentation of any groin swelling, there is need for an early accurate diagnosis followed by prompt treatment. The delay in its diagnosis and management may result in this rare complication of spontaneous faecal fistula. This reflects the state of health care in the developing world and needs to be addressed by the concerned authorities.

Richter’s Hernia: A Case Report

“…It may also cause abscess formation leading to enterocutaneous fistula in case when perforation develops. Rate of gangrene formation in Richter's hernia is faster as compared to other varieties of hernia 2,6 . Richter's hernia's diagnosis is difficult due to presence of early strangulation and absence of obstructive symptoms that increases mortality to 20-60% [2][3][4][5] .…”

“…In year 1598, Fabricius Hildanus described the first case of Richter's hernia. Then in 1778, German surgeon August Gottlieb Richter introduced the 1 st scientific description of the disease [4][5][6] . In year 1897, Sir Frederick Treves describes the Richter's hernia as protrusion of small part of circumference of intestine in which the protruded part carries significant risk of becoming gangrenous 4,7 .…”

Spontaneous inguinal enterocutaneous fistula, as an exceptional complication of incarcerated Richter’s hernia: A case report

“…It occurs at various positions with femoral ring being the most common. [2]. It is a more common disease in developing countries because of the delay in diagnosis [3].…”

Hérnia de Richter

“…A Hérnia de Richter (HR) é uma hérnia abdominal em que apenas parte da circunferência do intestino é aprisionada e estrangulada no orifício herniário [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] . Pode ocorrer em qualquer local usual de hérnia, sendo mais comum em anel femoral 1,[4][5][6]9,11,13,14 . O íleo terminal é o segmento mais frequentemente envolvido [1][2][3][4][5][6][7]9,13,14 .…”

“…Pode ocorrer em qualquer local usual de hérnia, sendo mais comum em anel femoral 1,[4][5][6]9,11,13,14 . O íleo terminal é o segmento mais frequentemente envolvido [1][2][3][4][5][6][7]9,13,14 . Representa 6% -10 % do total das hérnias estranguladas e progride mais rapidamente para gangrena do que as demais hérnias estranguladas 1,2,7,13,14 .…”