A case of obturator hernia with overlooked Howship-Romberg sign and treated as sciatica

Abstract

We report a case of a patient with incarcerated obturator hernia who presented with right thigh pain. An 88-year-old woman who had experienced right thigh pain for the previous 3 years was given a diagnosis of sciatica at the orthopedic department. In July 2009, she was hospitalized with the chief complaint of appetite loss. The day after admission she experienced increased right thigh pain and lower abdominal pain. Abdominal ultrasonography revealed a keyboard sign. Based on this finding, we diagnosed an ileus, which was alleviated by the insertion of an ileus tube. However, after the removal of the ileus tube, her right thigh pain recurred. Therefore, a diagnosis of hernia was considered. Contrast-enhanced computed tomography revealed an incarcerated bowel in the region between the pectineus muscle and muscle obturator. Laparotomy showed that the ileal part located about 15 cm from the terminal ileum was incarcerated in the right foramen obturatum; therefore, ileal resection and end-to-end anastomosis were performed. After the operation, her intestinal obstruction symptoms and right pain disappeared. If right pain and ileus symptoms of unknown cause occur in elderly persons, obturator hernia should be considered.

Howship-Romberg Sign and Bowel Obstruction: A Case Report

“…Obturator hernias are difficult to diagnose and 80% of patients present with small bowel obstruction symptoms in the form of crampy abdominal pain that can be vague some times, with nausea and vomiting [6]. Symptoms confusing with sciatica has been reported [7]. While flexion of the thigh usually relieves pain in patients with obturator hernia, it has not been reported as a presenting symptom as we describe in our case.…”

The Feasibility and Potential Advantages of Laparoscopic Management of Incarcerated Obturator Hernia Over the Open Approach

“…Although obturator hernia is relatively insidious, Howhip-Romberg sign is still important in the diagnosis of IOH, which is an indication of obturator nerve irritation resulting in pain radiates from the inner thigh to the knee, accounting for 37% to 60% of all patients. [11][12][13][14] In fact, CT examination is widely used for the diagnosis of IOH with an accuracy of over 90%, which is also considered the gold standard for diagnosis. 11,15,16 CT scan demonstrated incarcerated small bowel in obturator region with signs of proximal intestinal obstruction.…”

Obturator hernia: A diagnostic challenge

“…It is defined as a pain in the lower limbs caused by compression of the obturator nerve by the hernia in the obturator canal. Some studies have reported that the Howship-Romberg sign is seen in 37% to 60% of cases [6–8]. However, OH tends to develop in thin, aged women, who cannot describe their symptoms due to dementia.…”

“…Some papers reported that the mortality for complicated OH was 12–70% [11]. Thus, in principle, essentially all patients must undergo surgery, whether laparotomy or a laparoscopic operation [6]. Furthermore, many patients undergo surgery to prevent the recurrence of OH.…”