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The inguinal hernia: Not always straightforward, not always a hernia
The Journal
of Emergency
Medrone,
Vol. 7, pp. 21-24.
PrInted I” the USA
1989
l
CopyrIght
‘
Press plc
THE INGUINAL HERNIA: NOT ALWAYS STRAIGHTFORWARD, NOT ALWAYS A HERNIA Harold F. Sherman, Reprint
address:
Department Harold
of Surgery, F. Sherman,
FACS
University of South Florida, Tampa, Florida MD, FACS 2401 Bayshore Blvd., #605, Tampa,
FL 33629
presented to the emergency department with complaints of the acute onset of a painful swelling in his right groin. The pain began earlier the day of admission while lifting a five gallon paint can into a pickup truck. The pain was associated with vague lower abdominal discomfort and nausea. There were no other associated symptoms. The patient had no previous history of abdominal or groin herniae. He denied antecedent trauma. Physical examination demonstrated a generally healthy male, anxious and uncomfortable, but in no acute distress. His vital signs were normal and without orthostatic changes. The abdomen was soft and flat with mild bilateral lower abdominal tenderness. There was no guarding, rebound tenderness, nor other sign of peritoneal irritation. Bowel sounds were active. There was a large, easily reducible right inguinal hernia with extension into the scrotum. The hernial content was nontender and did not transilluminate in the scrotum. Rectal examination was normal. The WBC count was 18,500/mm3, with 88% pmn’s and 5% bands. The hematocrit was 38.2%. The remainder of the laboratory evaluation as well as abdominal and chest x-ray studies were unremarkable. Surgery was scheduled for two days following the patient’s presentation. In the interval there were no clinical changes and laboratory studies were not repeated. At inguinal exploration, a fluid-filled indirect hernia sac was identified and found to contain free flowing, nonclotting blood which, after a small amount of darker blood was aspirated from the peritoneal cavity, became bright red. A midline celiotomy was performed. The patient was found to have active bleeding from a diffuse surface of the spleen where a
0 Abstract -Swelling in the groin may represent much more than an inguinal hernia and an inguioal hernia may be much more complicated than it seems upon superficial consideration. Intraperitoneal or retroperitoneal hemorrhage as well as many other congenital, inflammatory, infectious, or neoplastic processes occurring either locally or at distance from the groin may present in the groin, simulating a hernia, or within an ioguinal hernia sac itself. Delayed and spontaneous rupture of the spleen are not rare occurrences. The case discussed, an episode of delayed rupture of the spleen presenting as blood within an inguinal hernia sac, servesto emphasize that following a complete clinical evaluation many entities other than simple inguinal hernia must be considered if a thorough differential diagnosis of a groin mass is to be developed. 0 Keywords-hernia; spleen; delayed rupture; spontaneous rupture; groin mass
INTRODUCTION When a physician is presented with a patient complaining of a swelling in the groin, it is all too easy to make the diagnosis of inguinal hernia and stop there. In fact, the swelling may represent many processes other than a hernia. Moreover even a hernia, when present, because of its anatomic relationships may reflect another, perhaps more significant process occurring at distance from the groin. The case presented depicts such a situation.
CASE HISTORY The patient, a previously well twenty-year-old
MD,
male,
RECEIVED: 25 September 1987; SECONDSUBMISSION RECEIVED:22 March 1988 ACCEPTED: 4 May 1988 21
0736X579/89 $3.00 + .OO
22
Harold F. Sherman
subcapsular hematoma had ruptured and denuded the spleen of much of its capsule. Attempts at splenic salvage were unsuccessful and the patient underwent a splenectomy combined with right inguinal herniorrhaphy. The postoperative course was benign, and the patient was discharged six days following surgery. Throughout the postoperative period, the patient persisted in his denial of recollected trauma which might have caused splenic injury. There was no clinical nor laboratory evidence of mononucleosis or other pathological process which would have made the spleen abnormally susceptible to injury or spontaneous rupture.
DISCUSSION Various well described entities may simulate or present within an inguinal hernia. In this manner, the hernia may serve as a sentinel to intraabdominal or extraabdominal processes which must be considered if an accurate differential diagnosis is to be developed. The concept of delayed splenic rupture is an old one that has undergone much reexamination and redefinition. Prior to modern diagnostic modalities, the diagnosis of splenic injury was dependent upon physical signs and symptoms which, all too frequently, were subtle or masked by concurrent injury. Thus, the opportunity for diagnosis was often delayed until clear signs of intraabdominal hemorrhage appeared. This interval between injury and the manifestation of hemorrhage was described by Baudet (1) in 1907 as the “latent period” and was proposed to occur in 15 % to 20% of patients with splenic injury. While periods up to five years have been reported (2), the asymptomatic latent period has generally been accepted as ranging from 24 to 48 hours up to two weeks. The latent period is explained by the occurrence of a subcapsular hematoma, which itself may cause few physical signs or symptoms, followed later by rupture of the splenic capsule. This is perhaps secondary to further splenic hemorrhage. With resultant intraperitoneal bleeding appears the more recognizable constellation of physical and physiological manifestations. Modern diagnostic modalities, including visceral angiography, peritoneal lavage, ultrasonography, nuclear scintigraphy, and computed tomography have served to increase’the accuracy of the early diagnosis of splenic rupture. The effect of these changes has been to lower the reported rates of true delayed splenic rupture to 1% to 2% (3,4), while earlier reported cases have largely been relegated to the category of delayed diagnosis rather than delayed rupture (3).
In contrast to delayed rupture, spontaneous rupture of the spleen occurs in the absence of significant trauma. Three additional criteria have been described as necessary for the diagnosis of spontaneous rupture of a normal spleen. These are: absence of disease processes that could adversely affect the spleen and lead to rupture; absence of perisplenic scarring or adhesions suggesting previous injury; and normal splenic tissue (excluding the rupture) on gross and histologic examination (5). While spontaneous rupture of a completely normal spleen has been reported (5), a more common scenario is that of rupture, without trauma, of a spleen involved with an ongoing systemic disease process. This has been called by some a “pathologic” rupture of the spleen and is most frequently reported in conjunction with a diagnosis of infectious mononucleosis (6,7). A vast number of other pathological states have been associated with spontaneous splenic rupture and include; leukemias (8,9), Hodgkin’s lymphoma (10,l l), hemophilia (12), polyarteritis nodosa (13), rheumatoid arthritis (14), systemic lupus erythematosus (15), amyloidosis (16), and portal hypertension (17). Infectious causes include malaria, typhoid, typhus, actinomycosis, and subacute bacterial endocarditis (18) as well as acquired immunodeficiency syndrome (19). Although pregnancy is not specifically a pathological state, spontaneous rupture of the spleen has also been reported during pregnancy (20) and as a complication of anticoagulant use (21). Spontaneous splenic rupture may be encountered during the course of a previously diagnosed disease or may be the presenting symptom (7,8,10,13,16). In either case, the predominant syndrome is one of abdominal pain and acute blood loss. Hemorrhage from splenic rupture is but one distant cause of blood presenting within a hernia sac (22). Ruptured abdominal aortic aneurysm has been reported to present in a similar manner (23), while a nonspecific retroperitoneal hemorrhage has been reported as presenting in the inguinal canal, giving the appearance of a strangulated hernia (24). More recently, Sujka et al (25) have also described a case of delayed splenic rupture presenting as scrotal hematoma. Theoretically, intraperitoneal or retroperitoneal bleeding from any source could manifest itself similarly. In addition to hemorrhage, a constellation of diseases and pathological processes have been reported to present themselves within an inguinal hernia. These include appendicitis and appendicular abscess (26), tuberculous peritonitis (27), metastatic carcinoma (28), endometriosis (29), mutinous ascites (30), and the uterus in a male pseudohermaphrodite (31). Dermoid. cysts (32), multicystic retroperitoneal lym-
23
Hernia
phangioma (33), groin abscess, varicocele, torsion of a nondescended testicle, inguinally located megaureter (34), hydrocele of the canal of Nuck (35), encysted hydrocele of the spermatic cord, as well as any other process involving the skin, subcutaneous tissue, fat, or muscle in the groin may mimic the appearance of an inguinal hernia. Inguinal lymphadenitis of any etiology, including infectious, inflammatory, and neoplastic, is easily mistaken for an inguinal hernia. Neoplastic inguinal lymphadenopathy may be either primary or metastatic. Although the specifics of the case presented are most unusual, retrospective review reveals certain findings that could have directed the diagnosis in a more precise direction. The presence of lower abdominal pain and tenderness associated with nausea suggest the possibility of an intraabdominal process beyond a simple inguinal hernia. Additionally, the elevated leukocyte count with a left shift points to an acute process and, although non-specific, is associated with splenic rupture. Coupled with a hemato-
crit at the lower range of normal for a healthy young man, these findings could be interpreted as suggestive of intraabdominal bleeding with splenic rupture as a possible etiology. Gargour (22), In 1965, reported a case similar to the one presented here, although the history of trauma was more clearly defined and temporally proximate.
CONCLUSION
Swelling in the groin may represent much more than an inguinal hernia, and an inguinal hernia may be much more complicated than it seems upon superficial consideration. When observed, the presence of a groin mass must be combined with a thorough clinical evaluation so that a complete differential diagnosis may be arrived at by giving adequate consideration to other possible etiologies and associated conditions.
REFERENCES 1. Baudet R. Ruptures de la rate. Med Prat J Int Clin Therap. 1907;3:565-7. 2. Clark OH, Lin RC, Margaretten W. Spontaneous delayed splenic rupture: case report of a five year interval between trauma and diagnosis. J Trauma. 1975:15:245-9. 3. Benjamin CI, Engrave LH, Perry JF. Delayed rupture or delayed diagnosis of rupture of the spleen. Surg Gynecol Obstet. 1976;142:171-2. 4. Olsen WR, Polley TZ Jr. A second look at delayed splenic rupture. Arch Surg. 1977;112:422-5. 5. Orloff MJ, Peskin GW. Spontaneous rupture of the normal spleen-a surgical enigma. Arch Surg. 1958;106:1-11. 6. Rotolo JE. Spontaneous splenic rupture in infectious mononucleosis. Am J Emerg Med. 1987;5:383-5. 7. Frecentese DF, Cogbill TH. Spontaneous splenic rupture in infectious mononucleosis. Am Surg. 1987;53:521-3. 8. Wolfson IN, Corce EJ, Site FK: Acute leukemia with rupture of the spleen as initial symptom. N Engl J Med. 1954;251:7357. 9. Shih LY, Su IJ. Chronic myeloid leukemia manifesting as spontaneous splenic rupture and terminating in megakaryoblastic transformation. Med Pediatr Oncol. 1987;15:31-37. 10. Saba HI, Garcia W, Hartmann RC. Spontaneous rupture of the spleen; an unusual presenting feature in Hodgkin’s lymphoma. South Med J. 1983:76:247-9. 11. Beshar FN. Spontaneous rupture of the spleen in Hodgkin’s lymphoma. Clin Oncol. 1982;8:69-71. 12. Broo J, Newman PE. Spontaneous rupture of the spleen in hemophilia. Arch Int Med. 1965;115:595-7. 13. Ford GA, Bradley JR, Appleton DS, et al. Spontaneous splenic rupture in polyarteritis nodosa. Postgrad Med J. 1986;62:9656. 14. Haskard DO, Higgens CS, Temple LN, et al. Spontaneous rupture of the spleen in rheumatoid arthritis. Ann Rheum Dis. 1983;42:411-4. 15. Krauser RE. Spontaneous rupture of the spleen in systemic lupus erythematosus. JAMA. 1976;236:1149. 16. Kozicky OJ, Brandt LJ, Lederman M, et al. Splenic amyloidosis: a case report of spontaneous splenic rupture with a review of the pertinent literature. Am J Gastroent. 1987;82:582-7.
17. Thijs JC, Schneider AJ, VanKordelaar JM. Spontaneous rupture of the spleen complicating portal hypertension. Inten Care Med. 1983;9:299-300. 18. Hyun BH, Varga CF, Rubin RJ. Spontaneous and pathologic rupture of the spleen. Arch Surg. 1972;104:652-7. 19. Mirchandani HB, Mirchandani IH, Pak MS. Spontaneous rupture of the spleen due to acquired immunodeficiency syndrome in an intravenous drug abuser. Arch Path01 Lab Med. 1985;109:1114-6. 20. deGraff J, Pijpers PM. Spontaneous rupture of the spleen in the third trimester of pregnancy. Report of a case and review of the literature. Eur J Obstet Gynecol Reprod Biol. 1987;25:2437. 21. Soyer MT, Merck DE, Aldrete JS. Spontaneous rupture of the spleen, an unusual complication of anticoagulant therapy. Arch Surg. 1976; 111:610. 22. Gargour G, Whitelaw GP. An extraordinary case of a right inguinal mass or serendipity in the operating room. Boston Med Quarterly. 1965;16:87-8. 23. Grabowski EW, Pilcher DB. Ruptured abdominal aortic aneurysm manifesting as symptomatic hernia. Am Surg. 1981; 47:311-2. 24. Salah MW. Retroperitoneal hemorrhage simulating a strangulated inguinal hernia. Brit Med J. 1972:4:403. 25. Sujka NK, Evans EJ, Nigam A. Delayed rupture of the spleen presenting as a scrotal hematoma. J Trauma. 1986;26:856. 26. Carey LC. Acute appendicitis occurring in hernias: a report of 10 cases. Surg. 1967;61:236-8. 27. Taylor BA. Tuberculous peritonitis presenting in a hernia sac. J R Co11Surg Edinb. 1986:31:313-5. 28. Chen KT. Metastatic carcinoma in an inguinal hernia sac. J Surg Oncol. 1984;25:248-9. 29. Brzezinski A, Durst AL. Endometriosis presenting as an inguinal hernia. Am J Obstet Gvnecol. 1983:146:982-3. 30. Sampsel JW. Mutinous Ascitks presenting as inguinal hernia. Surg Rounds. 1988;11:105-7. 31. Singh KN, Samuel KC, Verma AP. Uterus presenting in inguinal hernia of a male pseudohermaphrodite. Indian J Path01 Bacterial. 1970;13:119-21.
24 32. Brightmore T. Dermoid cyst of the inguinal canal simulating a strangulated inguinal hernia. Br J Clin Pratt. 1971;25:191. 33. Kafka V, Navak K. Multicystic retroperitoneal lymphangioma in an infant appearing as an inguinal hernia. J Pediatr Surg. 1970;5:573.
Harold F. Sherman 34. Powell RW. Bilateral megaureters presenting as an inguinal hernia. J Pediatr Surg. 1985;20:175-6. 35. McElfatrick RA, Condon WB. Hydrocele of the canal of Nuck. A report of two cases. Rocky Mt Med J. 1975;73:112-3.
of Emergency
Medrone,
Vol. 7, pp. 21-24.
PrInted I” the USA
1989
l
CopyrIght
‘
Press plc
THE INGUINAL HERNIA: NOT ALWAYS STRAIGHTFORWARD, NOT ALWAYS A HERNIA Harold F. Sherman, Reprint
address:
Department Harold
of Surgery, F. Sherman,
FACS
University of South Florida, Tampa, Florida MD, FACS 2401 Bayshore Blvd., #605, Tampa,
FL 33629
presented to the emergency department with complaints of the acute onset of a painful swelling in his right groin. The pain began earlier the day of admission while lifting a five gallon paint can into a pickup truck. The pain was associated with vague lower abdominal discomfort and nausea. There were no other associated symptoms. The patient had no previous history of abdominal or groin herniae. He denied antecedent trauma. Physical examination demonstrated a generally healthy male, anxious and uncomfortable, but in no acute distress. His vital signs were normal and without orthostatic changes. The abdomen was soft and flat with mild bilateral lower abdominal tenderness. There was no guarding, rebound tenderness, nor other sign of peritoneal irritation. Bowel sounds were active. There was a large, easily reducible right inguinal hernia with extension into the scrotum. The hernial content was nontender and did not transilluminate in the scrotum. Rectal examination was normal. The WBC count was 18,500/mm3, with 88% pmn’s and 5% bands. The hematocrit was 38.2%. The remainder of the laboratory evaluation as well as abdominal and chest x-ray studies were unremarkable. Surgery was scheduled for two days following the patient’s presentation. In the interval there were no clinical changes and laboratory studies were not repeated. At inguinal exploration, a fluid-filled indirect hernia sac was identified and found to contain free flowing, nonclotting blood which, after a small amount of darker blood was aspirated from the peritoneal cavity, became bright red. A midline celiotomy was performed. The patient was found to have active bleeding from a diffuse surface of the spleen where a
0 Abstract -Swelling in the groin may represent much more than an inguinal hernia and an inguioal hernia may be much more complicated than it seems upon superficial consideration. Intraperitoneal or retroperitoneal hemorrhage as well as many other congenital, inflammatory, infectious, or neoplastic processes occurring either locally or at distance from the groin may present in the groin, simulating a hernia, or within an ioguinal hernia sac itself. Delayed and spontaneous rupture of the spleen are not rare occurrences. The case discussed, an episode of delayed rupture of the spleen presenting as blood within an inguinal hernia sac, servesto emphasize that following a complete clinical evaluation many entities other than simple inguinal hernia must be considered if a thorough differential diagnosis of a groin mass is to be developed. 0 Keywords-hernia; spleen; delayed rupture; spontaneous rupture; groin mass
INTRODUCTION When a physician is presented with a patient complaining of a swelling in the groin, it is all too easy to make the diagnosis of inguinal hernia and stop there. In fact, the swelling may represent many processes other than a hernia. Moreover even a hernia, when present, because of its anatomic relationships may reflect another, perhaps more significant process occurring at distance from the groin. The case presented depicts such a situation.
CASE HISTORY The patient, a previously well twenty-year-old
MD,
male,
RECEIVED: 25 September 1987; SECONDSUBMISSION RECEIVED:22 March 1988 ACCEPTED: 4 May 1988 21
0736X579/89 $3.00 + .OO
22
Harold F. Sherman
subcapsular hematoma had ruptured and denuded the spleen of much of its capsule. Attempts at splenic salvage were unsuccessful and the patient underwent a splenectomy combined with right inguinal herniorrhaphy. The postoperative course was benign, and the patient was discharged six days following surgery. Throughout the postoperative period, the patient persisted in his denial of recollected trauma which might have caused splenic injury. There was no clinical nor laboratory evidence of mononucleosis or other pathological process which would have made the spleen abnormally susceptible to injury or spontaneous rupture.
DISCUSSION Various well described entities may simulate or present within an inguinal hernia. In this manner, the hernia may serve as a sentinel to intraabdominal or extraabdominal processes which must be considered if an accurate differential diagnosis is to be developed. The concept of delayed splenic rupture is an old one that has undergone much reexamination and redefinition. Prior to modern diagnostic modalities, the diagnosis of splenic injury was dependent upon physical signs and symptoms which, all too frequently, were subtle or masked by concurrent injury. Thus, the opportunity for diagnosis was often delayed until clear signs of intraabdominal hemorrhage appeared. This interval between injury and the manifestation of hemorrhage was described by Baudet (1) in 1907 as the “latent period” and was proposed to occur in 15 % to 20% of patients with splenic injury. While periods up to five years have been reported (2), the asymptomatic latent period has generally been accepted as ranging from 24 to 48 hours up to two weeks. The latent period is explained by the occurrence of a subcapsular hematoma, which itself may cause few physical signs or symptoms, followed later by rupture of the splenic capsule. This is perhaps secondary to further splenic hemorrhage. With resultant intraperitoneal bleeding appears the more recognizable constellation of physical and physiological manifestations. Modern diagnostic modalities, including visceral angiography, peritoneal lavage, ultrasonography, nuclear scintigraphy, and computed tomography have served to increase’the accuracy of the early diagnosis of splenic rupture. The effect of these changes has been to lower the reported rates of true delayed splenic rupture to 1% to 2% (3,4), while earlier reported cases have largely been relegated to the category of delayed diagnosis rather than delayed rupture (3).
In contrast to delayed rupture, spontaneous rupture of the spleen occurs in the absence of significant trauma. Three additional criteria have been described as necessary for the diagnosis of spontaneous rupture of a normal spleen. These are: absence of disease processes that could adversely affect the spleen and lead to rupture; absence of perisplenic scarring or adhesions suggesting previous injury; and normal splenic tissue (excluding the rupture) on gross and histologic examination (5). While spontaneous rupture of a completely normal spleen has been reported (5), a more common scenario is that of rupture, without trauma, of a spleen involved with an ongoing systemic disease process. This has been called by some a “pathologic” rupture of the spleen and is most frequently reported in conjunction with a diagnosis of infectious mononucleosis (6,7). A vast number of other pathological states have been associated with spontaneous splenic rupture and include; leukemias (8,9), Hodgkin’s lymphoma (10,l l), hemophilia (12), polyarteritis nodosa (13), rheumatoid arthritis (14), systemic lupus erythematosus (15), amyloidosis (16), and portal hypertension (17). Infectious causes include malaria, typhoid, typhus, actinomycosis, and subacute bacterial endocarditis (18) as well as acquired immunodeficiency syndrome (19). Although pregnancy is not specifically a pathological state, spontaneous rupture of the spleen has also been reported during pregnancy (20) and as a complication of anticoagulant use (21). Spontaneous splenic rupture may be encountered during the course of a previously diagnosed disease or may be the presenting symptom (7,8,10,13,16). In either case, the predominant syndrome is one of abdominal pain and acute blood loss. Hemorrhage from splenic rupture is but one distant cause of blood presenting within a hernia sac (22). Ruptured abdominal aortic aneurysm has been reported to present in a similar manner (23), while a nonspecific retroperitoneal hemorrhage has been reported as presenting in the inguinal canal, giving the appearance of a strangulated hernia (24). More recently, Sujka et al (25) have also described a case of delayed splenic rupture presenting as scrotal hematoma. Theoretically, intraperitoneal or retroperitoneal bleeding from any source could manifest itself similarly. In addition to hemorrhage, a constellation of diseases and pathological processes have been reported to present themselves within an inguinal hernia. These include appendicitis and appendicular abscess (26), tuberculous peritonitis (27), metastatic carcinoma (28), endometriosis (29), mutinous ascites (30), and the uterus in a male pseudohermaphrodite (31). Dermoid. cysts (32), multicystic retroperitoneal lym-
23
Hernia
phangioma (33), groin abscess, varicocele, torsion of a nondescended testicle, inguinally located megaureter (34), hydrocele of the canal of Nuck (35), encysted hydrocele of the spermatic cord, as well as any other process involving the skin, subcutaneous tissue, fat, or muscle in the groin may mimic the appearance of an inguinal hernia. Inguinal lymphadenitis of any etiology, including infectious, inflammatory, and neoplastic, is easily mistaken for an inguinal hernia. Neoplastic inguinal lymphadenopathy may be either primary or metastatic. Although the specifics of the case presented are most unusual, retrospective review reveals certain findings that could have directed the diagnosis in a more precise direction. The presence of lower abdominal pain and tenderness associated with nausea suggest the possibility of an intraabdominal process beyond a simple inguinal hernia. Additionally, the elevated leukocyte count with a left shift points to an acute process and, although non-specific, is associated with splenic rupture. Coupled with a hemato-
crit at the lower range of normal for a healthy young man, these findings could be interpreted as suggestive of intraabdominal bleeding with splenic rupture as a possible etiology. Gargour (22), In 1965, reported a case similar to the one presented here, although the history of trauma was more clearly defined and temporally proximate.
CONCLUSION
Swelling in the groin may represent much more than an inguinal hernia, and an inguinal hernia may be much more complicated than it seems upon superficial consideration. When observed, the presence of a groin mass must be combined with a thorough clinical evaluation so that a complete differential diagnosis may be arrived at by giving adequate consideration to other possible etiologies and associated conditions.
REFERENCES 1. Baudet R. Ruptures de la rate. Med Prat J Int Clin Therap. 1907;3:565-7. 2. Clark OH, Lin RC, Margaretten W. Spontaneous delayed splenic rupture: case report of a five year interval between trauma and diagnosis. J Trauma. 1975:15:245-9. 3. Benjamin CI, Engrave LH, Perry JF. Delayed rupture or delayed diagnosis of rupture of the spleen. Surg Gynecol Obstet. 1976;142:171-2. 4. Olsen WR, Polley TZ Jr. A second look at delayed splenic rupture. Arch Surg. 1977;112:422-5. 5. Orloff MJ, Peskin GW. Spontaneous rupture of the normal spleen-a surgical enigma. Arch Surg. 1958;106:1-11. 6. Rotolo JE. Spontaneous splenic rupture in infectious mononucleosis. Am J Emerg Med. 1987;5:383-5. 7. Frecentese DF, Cogbill TH. Spontaneous splenic rupture in infectious mononucleosis. Am Surg. 1987;53:521-3. 8. Wolfson IN, Corce EJ, Site FK: Acute leukemia with rupture of the spleen as initial symptom. N Engl J Med. 1954;251:7357. 9. Shih LY, Su IJ. Chronic myeloid leukemia manifesting as spontaneous splenic rupture and terminating in megakaryoblastic transformation. Med Pediatr Oncol. 1987;15:31-37. 10. Saba HI, Garcia W, Hartmann RC. Spontaneous rupture of the spleen; an unusual presenting feature in Hodgkin’s lymphoma. South Med J. 1983:76:247-9. 11. Beshar FN. Spontaneous rupture of the spleen in Hodgkin’s lymphoma. Clin Oncol. 1982;8:69-71. 12. Broo J, Newman PE. Spontaneous rupture of the spleen in hemophilia. Arch Int Med. 1965;115:595-7. 13. Ford GA, Bradley JR, Appleton DS, et al. Spontaneous splenic rupture in polyarteritis nodosa. Postgrad Med J. 1986;62:9656. 14. Haskard DO, Higgens CS, Temple LN, et al. Spontaneous rupture of the spleen in rheumatoid arthritis. Ann Rheum Dis. 1983;42:411-4. 15. Krauser RE. Spontaneous rupture of the spleen in systemic lupus erythematosus. JAMA. 1976;236:1149. 16. Kozicky OJ, Brandt LJ, Lederman M, et al. Splenic amyloidosis: a case report of spontaneous splenic rupture with a review of the pertinent literature. Am J Gastroent. 1987;82:582-7.
17. Thijs JC, Schneider AJ, VanKordelaar JM. Spontaneous rupture of the spleen complicating portal hypertension. Inten Care Med. 1983;9:299-300. 18. Hyun BH, Varga CF, Rubin RJ. Spontaneous and pathologic rupture of the spleen. Arch Surg. 1972;104:652-7. 19. Mirchandani HB, Mirchandani IH, Pak MS. Spontaneous rupture of the spleen due to acquired immunodeficiency syndrome in an intravenous drug abuser. Arch Path01 Lab Med. 1985;109:1114-6. 20. deGraff J, Pijpers PM. Spontaneous rupture of the spleen in the third trimester of pregnancy. Report of a case and review of the literature. Eur J Obstet Gynecol Reprod Biol. 1987;25:2437. 21. Soyer MT, Merck DE, Aldrete JS. Spontaneous rupture of the spleen, an unusual complication of anticoagulant therapy. Arch Surg. 1976; 111:610. 22. Gargour G, Whitelaw GP. An extraordinary case of a right inguinal mass or serendipity in the operating room. Boston Med Quarterly. 1965;16:87-8. 23. Grabowski EW, Pilcher DB. Ruptured abdominal aortic aneurysm manifesting as symptomatic hernia. Am Surg. 1981; 47:311-2. 24. Salah MW. Retroperitoneal hemorrhage simulating a strangulated inguinal hernia. Brit Med J. 1972:4:403. 25. Sujka NK, Evans EJ, Nigam A. Delayed rupture of the spleen presenting as a scrotal hematoma. J Trauma. 1986;26:856. 26. Carey LC. Acute appendicitis occurring in hernias: a report of 10 cases. Surg. 1967;61:236-8. 27. Taylor BA. Tuberculous peritonitis presenting in a hernia sac. J R Co11Surg Edinb. 1986:31:313-5. 28. Chen KT. Metastatic carcinoma in an inguinal hernia sac. J Surg Oncol. 1984;25:248-9. 29. Brzezinski A, Durst AL. Endometriosis presenting as an inguinal hernia. Am J Obstet Gvnecol. 1983:146:982-3. 30. Sampsel JW. Mutinous Ascitks presenting as inguinal hernia. Surg Rounds. 1988;11:105-7. 31. Singh KN, Samuel KC, Verma AP. Uterus presenting in inguinal hernia of a male pseudohermaphrodite. Indian J Path01 Bacterial. 1970;13:119-21.
24 32. Brightmore T. Dermoid cyst of the inguinal canal simulating a strangulated inguinal hernia. Br J Clin Pratt. 1971;25:191. 33. Kafka V, Navak K. Multicystic retroperitoneal lymphangioma in an infant appearing as an inguinal hernia. J Pediatr Surg. 1970;5:573.
Harold F. Sherman 34. Powell RW. Bilateral megaureters presenting as an inguinal hernia. J Pediatr Surg. 1985;20:175-6. 35. McElfatrick RA, Condon WB. Hydrocele of the canal of Nuck. A report of two cases. Rocky Mt Med J. 1975;73:112-3.