The delicate balance between over- and underdiagnosis in older people: a simple inguinal hernia?

An 87-year old man repeatedly presented at our emergency department with vomiting, abdominal distension and diarrhoea. He was diagnosed with episodes of gastroenteritis and swiftly recovered with supportive therapy. No further diagnostics were performed. However, at the umpteenth presentation with similar symptoms an abdominal CT scan was performed, showing small bowel obstruction caused by an incarcerated inguinal hernia (Figure 1).

Figure 1

Abdominal CT scan after intravenous contrast administration demonstrating (A) distention of the stomach and the small intestine in the left hemi-abdomen (B) entering a 5 cm wide right sided inguinal hernia. The herniated mesentery shows signs of venous congestion with multiple dilated vessels in the centre surrounded by fluid (C) and fat stranding in the surrounding soft tissue, suspected for incarceration of the hernia (D).

Older patients are more susceptible to inguinal herniation due to weakening of abdominal musculature [1]. Prompt diagnosis of incarcerated hernia and small bowel obstruction, is paramount to prevent mortality [2]. The reluctance to perform further diagnostics in older patients leads to significant underdiagnosis and undertreatment [3]. In particular, if such underdiagnosis is based upon perceived harm of surgery. As such, this case underlines that common surgical diagnoses, highly prevalent in the older population, may be overlooked. Although we may be more careful in considering surgery as treatment option in older patients, we nonetheless should be all the more diligent in early detection of surgical conditions, to prevent fatal consequences of underdiagnosis.

Declaration of Conflicts of Interest: None.

Declaration of Sources of Funding: None.

Declaration of Consent: Written informed consent for publication of clinical information and images was obtained from the patient.