Hernia (2008) 12:431–432
DOI 10.1007/s10029-008-0333-9
C A S E RE P O RT
Lower gastrointestinal bleeding: an unusual manifestation
of inguinal hernia
V. H. Chong · A. Z. F. Jamaludin · H. A. J. A. Mackie
Received: 30 July 2007 / Accepted: 18 December 2007 / Published online: 24 January 2008
© Springer-Verlag 2008
Abstract Inguinal hernia is a common condition that usu-
ally presents with swelling and mild groin discomfort.
Complications include bowel obstruction and strangulation.
We report a case of a 50 year-old man who developed
lower gastrointestinal bleeding secondary to an indirect
inguinal hernia. Colonoscopy showed an ileocecal valve
polyp, Xorid inXammation of cecum and ascending colon
and ulcerations of the terminal ileum. Histology showed
nonspeciWc colitis and angiodysplasia of the polyp. Surgi-
cal correction of the hernia led to the resolution of the endo-
scopic changes. The trauma associated with intermittent
herniation of small bowel probably led to ischemia, result-
ing in the observed changes.
Keywords Complication · Bleeding · Endoscopy · Hernia
Introduction
Inguinal hernia is a commonly encountered condition that
usually presents with swelling and mild groin discomfort
[1, 2]. Most are managed with elective surgery. However,
presentations with complicated hernias are not uncommon
and these include bowel obstruction and strangulation.
These are surgical emergencies and would require urgent
V. H. Chong (&) · A. Z. F. Jamaludin
Gastroenterology Unit, Department of Medicine,
Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital,
Bandar Seri Begawan, BA 1710, Brunei Darussalam
e-mail: chongvuih@yahoo.co.uk
H. A. J. A. Mackie
Department of Surgery,
Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital,
Bandar Seri Begawan, BA 1710, Brunei Darussalam
surgery [3, 4]. We present an interesting case of lower gas-
trointestinal (GI) bleeding secondary to an indirect inguinal
hernia.
Case report
A 50-year-old man was admitted with pain and swelling of
the right groin region of one day duration. There was also
one episode of vomiting. The only signiWcant medical his-
tory included hypertension and a long-standing intermittent
right groin swelling that had been present since childhood.
The previous episodes had resolved spontaneously without
requiring any consultation. Clinical examination revealed a
large tense non-tender swelling of the right inguinal area
associated with scrotal swelling consistent with an inguinal
hernia. The rest of the examination was unremarkable and
there was no evidence of bowel obstruction or strangula-
tion. Admission investigations only showed leukocytosis of
20 £ 109 (normal, 4.0–11 £ 109). The other laboratory
investigations were normal.
As he was mildly symptomatic, he was managed conser-
vatively with analgesia. The hernia was reducible after a
few hours of bed rest. The patient developed one episode of
fresh bleeding per rectum without any hemodynamic com-
promise on the following day (day 2). Colonoscopy was
done on the following day (day 3) and this showed an ileo-
cecal valve polyp, Xorid inXammation and ulcerations
extending from the distal terminal ileum to the ascending
colon (Fig. 1). Initial diVerential diagnosis included
Crohn’s disease or tuberculosis. The biopsies showed
edematous lamina propria with moderate acute and chronic
inXammatory inWltrates consistent with nonspeciWc inXam-
mation. There was no granuloma and no abnormal cells
were seen. Examination of the polyp showed dilated sub-
123
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Fig. 1a–c Florid inXammation
in the ascending colon and
cecum (a); polypoidal lesion in
the ileocecal valve area (b); mul-
tiple superWcial ulceration in the
terminal ileum (c)
mucosa endothelial-lined blood vessels extending into the
mucosa, consistent with angiodysplasia.
As the patient was asymptomatic with no further bleed-
ing and a benign histology, it was decided to proceed with
hernia repair instead of the initially considered limited right
hemicolectomy. The surgery was carried out on day 4
under spinal anesthesia. Surgery showed a loop of viable
small bowel (terminal ileum) within the indirect hernia sac,
and this was reduced into the peritoneal cavity. The proxi-
mal sac was transWxed with vicryl suture and the distal sac
left in situ. Darn repair was done with surgidac.
The patient was discharged the following day (day 5)
and did not have any further recurrence of the hernia or
bleeding. A colonoscopy was repeated three months later
and this showed complete resolution of the aVected areas.
Discussion
To our knowledge, lower GI bleeding secondary to compli-
cated inguinal hernia has never been reported before. Like
hernia, lower GI bleeding is also a commonly encountered
condition. As such, the coexistence of these two conditions
would be expected. Most bleeding episodes are self-limit-
ing and can be managed conservatively without any surgi-
cal interventions. Hemorrhoids, diverticular disease and
angiodysplasia account for the majority of these cases [5,
6]. However, it is very important to rule out more signiW-
cant causes, such as colorectal neoplasms, particularly in
elderly populations.
The underlying mechanism of bowel injury seen in our
case is probably similar to that of bowel incarceration.
Repeated traumas as a result of repeated herniation of the
small bowel would result in bowel ischemia. Strangulation
occurs when vascular compromise is complete. Ischemic
changes are seen if compromise is incomplete, as shown in
our case. Bowel lumen occlusion will result in bowel
obstruction. Other conditions, such as solitary rectal ulcer
syndrome or gastric antral vascular ectasia are known to have
repeated mucosal trauma as the underlying pathogenesis but
exhibit various endoscopic and histological manifestations
[7, 8]. Both conditions commonly present with bleeding.
123
Hernia (2008) 12:431–432
The endoscopic Wndings seen in our case are probably
part of a spectrum of changes that would have been
observed in cases with bowel herniation. Despite the acute
presentation of our case, the presence of a polyp with angi-
odysplastic features suggests that the underlying process
had probably been active for quite some time, rather than it
just being an acute event. Further studies are required to
assess the spectrum of endoscopic Wndings that would be
seen to occur due to recurrent mucosal trauma from hernia.
Interestingly, there have been reports of incarceration of
colonoscope in patients with underlying hernia undergoing
colonoscopy [9, 10]. Therefore, all endoscopists need to be
aware of such complications.
In conclusion, although inguinal hernia is a commonly
encountered condition, it is important to be aware of the
less common manifestations, such lower GI bleeding sec-
ondary to bowel trauma. This will avoid misdiagnosis and
avoid any unnecessary surgery.
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