Incarcerated umbilical hernia in a patient with cirrhotic ascites in combination with chronic lymphocytic leukemia: a case report

Abstract

Umbilical hernia is a common type of extra-abdominal hernia in adults. However, chronic granulocytic leukemia in combination with cirrhotic ascites and renal insufficiency is less common. The patient reported here had both indications and contraindications for emergency surgery; therefore, the treatment options were subject to debate. We report the case of a man in his 60s who had a strangulated umbilical hernia, with overlying purple-colored infected and necrotic skin. The area was painful, but his bowel movements were normal. Patients underwent comprehensive conservative management, and remote follow-ups via telephone and video conferencing for a period of 60 days, during which the incarcerated contents of the hernia eventually retracted and his pain was relieved, such that there were no longer indications for emergency surgery. In addition, his skin infection disappeared and his quality of life improved, and therefore the treatment outcomes were good. Thus, we provide evidence that not all incarcerated umbilical hernias require emergency surgery, but may respond well to conservative treatment when the contents do not include intestinal loops or other critical organs.

Introduction

Umbilical hernia is a common extra-abdominal hernia in adults. Most are acquired, and the incidence of umbilical hernia is significantly higher in the presence of cirrhotic ascites. ¹ When intestinal loops or greater omentum are incarcerated or strangulated in the umbilical with prolonged incarceration, the risk of intestinal necrosis, perforation, or peritonitis will increase, which are life-threatening, and therefore require emergency surgery. However, this is associated with the risk of serious complications that may also be life-threatening. ² If accompanied by contraindications to surgery, such as severe hepatic or renal insufficiency, chronic granulocytic leukemia or substantial ascites, anesthesia is extremely risky and the postoperative prognosis of the patient is poor. Therefore, conservative treatment may also be an option, after performing the relevant investigations to exclude the possibility of incarceration of intestinal loops or other organs. In this report, we describe a specific treatment plan for such cases, as well as detailed clinical information and the outcomes of treatment of a specific case.

Case report

The patient was a man in his 60s who was admitted to hospital with an umbilical mass that had been present for >3 months, had been painful for 3 days and was difficult to reduce. The patient had been diagnosed with chronic lymphocytic leukemia 2 months previously at another hospital and was administering zebutinib. On admission, the following findings were made: an abdominal mass, generalized abdominal distension, abdominal breathing, a soft abdomen and varices of the abdominal wall. The umbilical mass was approximately 7 cm × 10 cm × 6 cm in size, the overlying skin was dark purple and malodorous and the surrounding skin was inflamed. The hernial contents could not be reduced and bowel sounds were detectable within. The laboratory test results were as follows: serum C-reactive protein 347 nmol/L, leukocyte count 58.48 × 10⁹/L, hemoglobin 112 g/L, serum cancer antigen (CA)-125 270.0 U/mL, serum albumin 435 μmol/L and serum bilirubin 40 µmol/L. Abdominal computed tomography showed cirrhosis of the liver, which was accompanied by a loss of compensation, pneumoperitoneum, and an umbilical hernia (Figure 1).

Figure 1.

Abdominal computed tomography images, showing (a) an umbilical hernia and fluid in the abdominal cavity; and (b) herniation of the abdominal contents, which show mixed echogenicity.

The patient had serious underlying conditions: Child–Pugh grade C liver function and chronic lymphocytic leukemia. A multidisciplinary consultation was conducted to discuss the patient’s hepatic and renal insufficiency, accompanied by substantial ascites, which rendered anesthesia extremely risky, and the high risk of infection and hemorrhage associated with the administration of zebutinib. The patient had a severe periumbilical skin infection, and therefore there was also a high risk of poor postoperative healing. The conclusions of the discussion were that surgery would be associated with high risk of complications, and was therefore contraindicated. Considering that the patient had no gastrointestinal symptoms and that the contents of the incarcerated hernia were most likely the greater omentum, it was decided that he should be treated conservatively. Therefore, the umbilical hernia was disinfected twice a day with 75% medical alcohol, and a mixture of atropine, recombinant human epidermal growth factor and gentamicin was sprayed onto gauze, which was applied to the lesion wet. After 2 weeks, the skin overlying the umbilical hernia showed atrophic sclerosis and the ascites had diminished, and therefore the patient was discharged. Subsequently, the umbilical hernia gradually improved and it was suggested that the patient could return to hospital for elective surgical treatment (Figure 2). However, the patient and his family refused this treatment. There were no remarkable changes during the remainder of the follow-up period.

Figure 2.

Effects of the treatment of the patient’s umbilical hernia. (a) Umbilical hernia, accompanied by local skin ischemia and inflammation, on admission. (b) The umbilical hernia and periumbilical skin inflammation had subsided after 1 week of conservative treatment. (c) Local crusting and shrinkage of the umbilical hernia after 2 weeks of treatment and (d) The umbilical hernia and periumbilical skin inflammation had substantially subsided 2 months after admission, and the contents of the hernia returned to the abdominal cavity while the patient was lying down.

The reporting of this case conforms to the CARE guidelines. ³ We obtained the written informed consent of the patient for treatment and for the publication of this case report. All the details of the patient have been deidentified. The requirement for ethics approval was waived because of the retrospective nature of the study.

Discussion

Umbilical hernia is an extra-abdominal hernia that is formed by the protrusion of abdominal contents beyond the abdominal wall via the weak area of the umbilicus. Most umbilical hernia in adults are acquired, and they account for approximately 6% of abdominal wall hernias. ⁴ However, the prevalence of umbilical hernia in patients with cirrhotic ascites is as high as 20%.^5–6 The substantial ascites that develops in the presence of cirrhosis leads to an increase in intra-abdominal pressure, resulting in the protrusion of intestinal loops, the greater omentum and/or other abdominal contents into the hernial sac. If this is associated with incarceration and strangulation of the intestine, emergency surgery is required, but this is associated with high incidences of reoperation and readmission and wound complications, along with a 15-fold higher incidence of mortality. ⁷ McKay et al. found that the prevalence and mortality rates associated with elective umbilical hernia repair are significantly lower than those for patients who undergo later repair. ⁸

Previously, patients with cirrhosis in combination with an incarcerated umbilical hernia were usually treated by emergency surgery. Indeed, there have been few reports of non-surgical management, and to the best of our knowledge, only one such case has been reported worldwide. ⁹ We compared this case with the present one (Table 1). For the patient reported by Alonso et al., ⁹ ultrasonographically-guided umbilical puncture was performed and 600 mL of fluid was drained from the hernia sac, then the hernia was successfully reduced. Six months following this procedure, the patient underwent open hernia repair that was not associated with any complications during the follow-up period. The present patient was in poor condition and had been diagnosed with cirrhotic decompensation, combined with chronic lymphatic leukemia, which rendered surgical treatment highly risky. The risks of poor postoperative wound healing and infection were judged to be extremely high and may have further aggravated the patient’s condition. The patient also showed signs of infection and necrosis of his umbilical skin, which meant that puncture and aspiration were contraindicated. However, given that the patient did not show signs of intestinal obstruction or intestinal necrosis, such as nausea, vomiting, constipation or flatulence, and on the basis of the computed tomography and other imaging findings, the incarcerated contents of the hernia were believed to be the greater omentum. Furthermore, the patient's family did not wish for surgery to be performed; therefore, conservative medical treatment was instituted.

Table 1.

Comparison of the characteristics of two cases of incarcerated umbilical hernia that were treated conservatively.

Author, year	Sex	Age (years)	Child–Pugh class	Treatment method	Skin color	Incarcerated contents
9 Alonso, 2015	Male	54	C	Umbilical paracentesis	Erythema	Ascitic fluid and small bowel
Present case	Male	60s	C	Topical treatment of peri-umbilical skin and conservative medical treatment	Dark purple and red peripherally	Ascitic fluid and greater omentum

We medically treated the umbilical hernia and peri-umbilical skin to avoid the development of Flood syndrome. ¹⁰ Initially, we used 75% alcohol wipes to disinfect the peri-umbilical skin, which promotes vascular endothelial cell function, promotes the local circulation, dehydrates the skin and coagulates proteins. Furthermore, the release of microorganisms in the secretion of sebaceous glands and exudation are reduced, thereby reducing the number of pathogenic bacteria present. After disinfection, 160,000 U of gentamicin and 1.0 mg of atropine were dissolved in 2000 U/mL of recombinant human epidermal growth factor topical solution and sprayed onto clean gauze for the wet dressing of the area. Gentamicin has an antibacterial effect on a variety of gram-positive and gram-negative bacteria; ¹¹ and gentamicin in combination with atropine has effects on subcutaneous blood vessels, improving the microcirculation, enhancing tissue perfusion, improving the supply of blood oxygen and nutrients, and promoting the reabsorption of oedema fluid. In addition, recombinant human epidermal growth factor significantly promotes wound healing in the skin. ¹² After disinfection of the affected area, the umbilical hernia and peri-umbilical skin inflammation subsided, the local pain receded, and the umbilical hernia resolved without further treatment after the ascites diminished.

In contrast to the established treatment for a strangulated umbilical hernia, the present patient was treated conservatively and the outcomes were positive. This implies that in some patients who demonstrate the incarceration of abdominal contents, such as the greater omentum, but in whom there are clear contraindications for surgery and no gastrointestinal symptoms are present, conservative treatment may be attempted. During this period, the patient’s abdominal symptoms should be closely monitored, and then elective umbilical hernia repair can be performed when the patient’s condition permits.

This case study was intrinsically limited by the fact that the conclusions were reached on the basis of the findings made with respect to an individual patient. Therefore, a statistical analysis of the outcomes could not be performed, and causal relationships between the clinical outcomes and the clinicopathological characteristics of the case cannot be ascribed.

In conclusion, we report a case of leukemia in combination with an incarcerated umbilical hernia, in which a satisfactory outcome was achieved by pharmacological and local lesion treatment. Our experiences with the present patient suggest an alternative approach to the treatment of such individuals. Patients with incarcerated hernias who have clear contraindications for surgery and do not present with gastrointestinal symptoms may respond to conservative treatment, until appropriate conditions for elective surgery can be achieved.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605231208574 - Supplemental material for Incarcerated umbilical hernia in a patient with cirrhotic ascites in combination with chronic lymphocytic leukemia: a case report

Supplemental material, sj-pdf-1-imr-10.1177_03000605231208574 for Incarcerated umbilical hernia in a patient with cirrhotic ascites in combination with chronic lymphocytic leukemia: a case report by Xiao-Tian Li, Man-Zhou Lin, Huan-De Chen and Ming Chen in Journal of International Medical Research

Supplemental Material

sj-pdf-2-imr-10.1177_03000605231208574 - Supplemental material for Incarcerated umbilical hernia in a patient with cirrhotic ascites in combination with chronic lymphocytic leukemia: a case report

Supplemental material, sj-pdf-2-imr-10.1177_03000605231208574 for Incarcerated umbilical hernia in a patient with cirrhotic ascites in combination with chronic lymphocytic leukemia: a case report by Xiao-Tian Li, Man-Zhou Lin, Huan-De Chen and Ming Chen in Journal of International Medical Research

Supplemental Material

sj-pdf-3-imr-10.1177_03000605231208574 - Supplemental material for Incarcerated umbilical hernia in a patient with cirrhotic ascites in combination with chronic lymphocytic leukemia: a case report

Supplemental material, sj-pdf-3-imr-10.1177_03000605231208574 for Incarcerated umbilical hernia in a patient with cirrhotic ascites in combination with chronic lymphocytic leukemia: a case report by Xiao-Tian Li, Man-Zhou Lin, Huan-De Chen and Ming Chen in Journal of International Medical Research