Case Report

A 43-year-old man was evaluated for left inguinal pain. He had not previously described swelling in the groin. For the week prior to admission, he noted increasing pain and swelling in the left inguinal region. He did not have fever. His abdomen was soft and not tender. The left inguinal region was markedly tender and swollen but there was no redness or drainage. Scrotal exam was normal. He was mildly anemic but WBC was normal. Other lab values were normal. The initial impression was that the patient had an incarcerated or strangulated inguinal hernia.

Abdominal CT scan was obtained (Figures 1, 2). The scan showed that the patient had gas in the inguinal canal tracking from a probable colonic source as well as diverticular disease and gas along the psoas muscle.

The inguinal canal was explored and a large foul-smelling abscess was drained. Laparoscopy and laparotomy were done. The sigmoid colon was dissected from a small defect at the internal ring. The segment of sigmoid diverticulitis was resected and an end sigmoid colostomy and Hartmann procedure were done. The patient recovered.

Figure 2

Figure 2: Gas is seen medial to the left psoas muscle

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Discussion

Most patients who present with acute inguinal symptoms of mass or pain have a hernia or some form of lymph node pathology. Occasionally the sigmoid colon is trapped in an inguinal hernia or makes up the wall of a sliding hernia on the left side. Rarely does one suspect a primary colonic process leading to inguinal symptoms.

While complicated diverticular disease is known to cause fistulae to the bladder or the vagina, it is an unusual cause of inguinal complaints. Andrabi recently reported a patient with a pre-existing inguinal hernia where perforating diverticulitis and abscess tracked along the round ligament and incarcerated omentum into the inguinal region. [1] deVries reported a patient with subcutaneous emphysema in the left groin caused by diverticular abscess tracking through a patent inguinal canal. [2] Girotto reported three patients treated for acute diverticulitis simulating strangulated inguinal hernia seen at one institution in a one-year period. [3] Greenberg treated this condition by initial drainage of the infected inguinal area followed by a laparoscopic resection of the diseased colon. [4] Bunting and colleagues treated their patient with drainage of the hernia, resection of involved sigmoid colon and primary anastomosis. [5] Our own patient did not know he had a hernia. His groin swelling was initially thought to represent a strangulated hernia. CT scan was helpful in showing that the patient had diverticulitis and he had drainage of the groin abscess, colostomy and Hartmann procedure.

Conclusion

While a tender inguinal swelling is usually the result of an incarcerated or strangulated inguinal hernia, physicians should be aware that complicated diverticular disease can occasionally cause inguinal symptoms. Modern imaging will help to show that the colon is the source of the inguinal symptoms. Once the diagnosis is made, the surgeon should plan treatment of both the primary colon problem and also the infection which presents in the groin.