Pre-Surgery Diagnosis Needed?

[drtowfigh]

Pre-Surgery Diagnosis Needed?

The area and symptoms may be due to a Spigelian or interstitial inguinal hernia. Hard to believe it was missed on CT but it’s been known to happen. A Valsalva image (CT or MRI) helps view small hernias best.

You can have your images re-read by a local radiologist as a consult or I am happy to review them. Ileostomy seems extreme for your problem and based on your GI workup is low likely to resolve your symptoms. Upon laparoscopy, the peritoneum needs to be taken down to be completely sure there is no hernia. I assume that was not done with your last laparoscopy. And during loop ileostomy depending on the technique they may not do anything more than a right lower quadrant incision.

[Vicki]

Pre-Surgery Diagnosis Needed?

My intestinal problems began over 2 years ago when I was doing a lot of heavy lifting; much more than what would be considered normal. I had also recently given birth at the age of 49 via c-section. My symptoms progressed to a complete inability to pass gas or formed stool, intense bloating, trapped gas, rectal pain/pressure, and chronic pain/pressure/throbbing on my left side, about 2″ to the left of my belly button and 2″ down. I am not thin, but if I press down very hard I feel a sore lump. I habitually press on it to relieve pressure and to try to push painful trapped gas or stool toward my rectum. Some doctors say this sensitive spot is my sigmoid colon and others say it is my scoaz muscle. But it is VERY sore 24/7, and becomes excruciatingly painful after I eat larger meals or exert myself. Two days ago I used an enema to try to relieve gas pressure and constipation. I filled my colon with 3 quarts of water, and the pressure was so extreme it felt as though a knife was piercing into the sore spot on my left side. A friend who is a doctor stopped by and palpated the lumpy spot and thought it was a spigelian hernia. I went to the ER and a CT Scan showed only the umbilical hernia. They believed a Spigelian Hernia would show a lump on my side and been clearly visible on a CT Scan, although I have read otherwise. The pain has prevented me from working, socializing or barely leaving my house for almost 2 years. I spend most time in bed, and recently started taking Vicodin to take the edge off. I have seen GI doctors, colorectal surgeons, Ob/Gyn, Nutrtionists, and Holistic Doctors. I traveled to The Cleveland Clinic and The Mayo Clinic for extensive testing. I had two colonoscopies, two sigmoidoscopies, Defecography, Anal Manometry, Balloon Expulsion, ALCAT Food Allergy Testing, Extensive Stool Analysis, extensive blood testing, Upper Endoscopy, SIBO Breath Test, Bowel Transit Study, several CT Scans, and exploratory Laparadcopy by my ObGyn to look for scar tissue and endometriosis. The only definitive finding from all this was mild rectal dyssynergia as a result of all the straining. Also the small bowel and large bowel transit were below average but not alarming. I requested the loop ileostomy because I felt I had exhausted all options and needed relief from the rectal pain, painful gas pressure, and unexplained pain in the sigmoid area… which I now believe to be a Spigelian hernia. I am concerned this may have been overlooked on the CT Scan because they are apparently very difficult to see. I am not clear as to whether the general surgeon will be able to see a Spigelian hernia during Ileostomy surgery since it is trapped between muscle tissue, or if it has to be located ahead of time. Obviously if a hernia is the culprit I would not do the ileostomy. Thanks for your help.

[drtowfigh]

Pre-Surgery Diagnosis Needed?

Intestinal problems can be very complicated to diagnose. There are a wide variety of causes of bloating including motility disorders, hypothyroidism, narcotics use, small intestinal bacterial overgrowth, etc. In addition, hernias can cause symptoms of bloating, nausea, abdominal pain.

Typically, the bloating, pain and nausea are due to direct involvement of intestine with the hernia. In my practice, I have also regularly seen patients without intestinal involvement of their hernia (ie, hernia with fat content only) who have bloating, nausea and this resolved after the hernia repair. In analyzing these, it seems that the nausea and bloating are the body’s reaction to the pain from the hernia.

A CT is adequate for evaluation of the abdomen. MRI is more useful for the pelvis. CT with Valsalva (beardown) would be preferable. A careful review of the CT would show the umbilical belly button hernia and any Spigelian hernia. Spigelian hernias typically occur two finger breadths below the level of the belly button and on the edge of the rectus muscle (the abs or six-pack). It sounds like you are describing pain at the same area.

I do not know what studies have been done to evaluate your GI tract. From what you have posted, there is no major motility disorder of the colon, which would be the only reason to perform an ileostomy, and even then that is a drastic procedure and still does not address the colon motility, which remains in situ.

Umbilical hernias may present with pain at their periphery, usually a couple of finger-breadths to the side, but not lower in the abdomen. You may have a simple inguinal hernia. That is much more common than a Soigelian hernia. In such a case, a dynamic MRI pelvis would be helpful. Also, as I explained above, your symptoms may be associated with an inguinal hernia. I have seen it in my practice dozens of times.

Do you notice any bulging or protrusion in the area? Is any of your nausea, bloating, pain associated with activity? Intercourse? Menses? Sitting? Coughing?