2303 A Rare Case of Atraumatic Intercostal and Intrathoracic Liver Herniation Related to Influenza A

Abstract

INTRODUCTION: A non-traumatic intercostal hernia is sparsely reported and is defined as a protrusion of intra-abdominal contents through acquired or congenital defect of the abdominal and thoracic walls. There have been individual cases reporting such herniation of lungs, small and large bowel, omentum, and liver. We describe a case in which a patient had both intercostal and diaphragmatic liver herniation secondary to increased cough. The literature relies on CT for diagnosis and for assessing damage to liver parenchyma which guides management. While intercostal liver herniations can be surgical emergencies, our case was managed conservatively given minimal liver injury and rapidly improving symptoms. CASE DESCRIPTION/METHODS: A 58-year-old female with a past medical history of hypothyroidism and essential hypertension presented with severe dry cough and nasal congestion for two weeks. Three days before presentation, she noticed a bruise on the right lateral chest wall which gradually increased and became painful with radiation to her back. The patient denied any recent history of trauma to the area. Physical exam revealed dry cough, large palpable tender bulging ecchymosis over right 9th and 10th ribs, and clear lungs. Vitals were unremarkable. Labs were significant for ALT 41, AST 62, CK 493, white count 17.8, platelets 567, INR 0.9 and positive nasal swab for influenza A. CT abdomen showed herniation of uninjured liver between 9th and 10th ribs with abdominal wall soft tissue stranding (or edema) with part of liver herniating through a diaphragmatic defect into the thoracic cavity (“hump sign”). Surgical services were consulted, and the patient was managed conservatively with opiate analgesia, IV hydration with normal saline, cough suppression, Tamiflu, and discharged with medical and surgical follow up. DISCUSSION: In patients with poor abdominal muscle strength having sudden worsening of pain after coughing and physical exam findings consistent with herniation, there should be high suspicion for abdominal and transdiaphragmatic herniation of liver. Given the rarity of such events, these patients can present as a diagnostic challenge and delay in care can result in poor outcomes especially in patients with organ damage. A consensus for management can be difficult due to sparsely reported cases, however, while injured or strangulated liver herniation is a surgical emergency, a conservative approach can be considered for uninjured liver herniation with close medical and surgical follow up.