Groin Mass in a 68-Year-Old Male (Case 5)

Chapter 15 Groin Mass in a 68-Year-Old Male (Case 5)



Ryan S. Hoffman, MD, Jonathan Gefen, MD




Differential Diagnosis




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Speaking Intelligently


When I see a patient with a groin mass, I start with a detailed hx that focuses on its onset, duration, and local symptoms, as well as any associated systemic symptoms. I look to see if the mass is tender, nonreducible, or pulsatile, and if there are any overlying skin changes. If nausea, vomiting, or abdominal pain are present, I obtain an obstruction series. If signs of strangulation are present, the patient should be prepared immediately for the OR. The dx of an incarcerated hernia is usually established by physical examination, but labs, abdominal films, and CT can be helpful in difficult cases.



PATIENT CARE



Clinical Thinking



• Consider the conditions in the differential dx that would lead to trouble quickly. An acutely incarcerated hernia is a surgical emergency because entrapped bowel can become ischemic very quickly.

• Do not attempt to reduce an incarcerated inguinal mass in the face of tenderness, peritonitis, or other suspicion that the mass is strangulated.

• An abscess requires immediate incision and drainage

• A pseudoaneurysm requires prompt intervention to prevent expansion and hemorrhage.


History



• Consider any previous hx leading up to the groin mass: previous hernia repair? femoral artery catheterization? How did the bulge begin and how does it feel now?

• Inguinal hernias are associated with a bulge and new onset of pain or discomfort with straining.

• Femoral hernias usually present in older females and often go unnoticed until incarceration or strangulation occurs.

• Lymphadenopathy may arise in the setting of infection or neoplasm; ask about fevers, rash, weight loss, or previous hx of neoplasm.


Physical Examination



• VS: Fever suggests an inflammatory process.

• Abdomen: A hernia that is tender and nonreducible is incarcerated. Strangulated bowel within the hernia can lead to local erythema or discoloration of the overlying skin, signs of peritonitis (rebound, guarding), or obstruction (distention, obstipation).

• Skin: Erythema and fluctuance with or without drainage is seen with an abscess.

• Lymph nodes: Lymphadenopathy appears as a firm, nonreducible, and sometimes tender nodular subcutaneous mass. Lymphoma is usually nontender and may present with enlarged nodes in multiple areas, including the cervical or axillary regions. A number of neoplasms can metastasize to the inguinal nodes; examine the skin (melanoma) and anorectal and genital regions (squamous cell carcinoma).

• A pulsatile, firm mass is characteristic of a pseudoaneurysm. Look for hx of recent femoral puncture (as in a cardiac catheterization patient or an IV drug abuser).


Tests for Consideration












• CBC: leukocytosis suggests an infectious process.
 $35

• Fine-needle aspiration: may be useful in distinguishing neoplastic vs. reactive lymphadenopathy. May confirm purulence in an abscess.
 $250



IMAGING CONSIDERATIONS















→ Obstruction series: Erect CXR and two-view abdomen series to evaluate for pneumoperitoneum, bowel obstruction, or pulmonary process.
 $225

→ Duplex ultrasonography of common femoral artery: Color Doppler evaluation of the common femoral artery and vein is diagnostic for pseudoaneurysm.
 $250

→ CT of abdomen/pelvis with oral/IV contrast: Generally not necessary to evaluate the inguinal region. However, if results of the physical examination are not definitive, as in the obese patient, CT may be useful to show sites of bowel obstruction, hernia, or masses not readily apparent.
 $800





















Clinical Entities Medical Knowledge
Inguinal Hernia
PΦ A defect in the abdominal wall at the internal ring (indirect hernia) or Hasselbach’s triangle (direct hernia). As the hernia enlarges, it may become nonreducible (incarcerated). Bowel that is present inside an incarcerated hernia may become obstructed or strangulated.
TP Most hernias present as a bulge in the inguinal region, sometimes accompanied by local discomfort. Initially, an acutely incarcerated hernia will produce persistent local pain. Nausea and vomiting suggest bowel obstruction; severe pain, tenderness, and overlying erythema suggest strangulation.
Dx The dx is almost always based on physical examination. An obstruction series or CT may be helpful to aid in the dx or to confirm obstruction if results of the physical examination are equivocal.
Tx Elective surgical repair is recommended for symptomatic hernias. For an acutely incarcerated hernia, manual reduction should be attempted if there are no signs of ischemia or obstruction. An elective repair should then be undertaken. If signs and symptoms of strangulation are present, emergent surgery is required. See Sabiston 44, Becker 16.


















Femoral Hernia
PΦ A femoral hernia develops in the small space medial to the femoral vein in the femoral canal. It is more likely to strangulate than an inguinal hernia because of the small, unforgiving space through which it occurs.
TP Intermittent bulging in the femoral region is common; however, a patient may be unaware of its presence until the hernia becomes incarcerated.
Dx Dx is based on physical examination, which reveals a hernia inferior to the inguinal ligament.
Tx Femoral hernias are managed surgically in the same manner as inguinal hernias. See Sabiston 44, Becker 16.


















Lymphadenopathy
PΦ Single or multiple lymph node enlargement may result from any local or systemic infection (e.g., cat-scratch fever) or inflammatory process that provokes a lymph node reaction. Lymphadenopathy in the groin may also be secondary to neoplasms, particularly lymphoma, melanoma of the lower extremities or lower trunk, and squamous neoplasia of the anorectum.
TP The patient may present with unexplained fevers, malaise, or weight loss, or with no associated symptoms whatsoever. Palpable adenopathy may be localized to a single lymph node basin or may be systemic.
Dx Fine-needle aspiration biopsy can be useful to distinguish reactive nodes from neoplasm. For a dx of lymphoma, open lymph node biopsy is necessary to assess nodal architecture.
Tx Tx depends on specific dx.


















Femoral Pseudoaneurysm
PΦ Following trauma to the femoral artery, bleeding from the artery is contained in the periarterial tissues, resulting in a pulsatile mass that communicates with the arterial lumen. It most often follows iatrogenic injury, as in cardiac catheterization or prior vascular surgery.
TP The typical patient has a pulsatile mass in the groin after a recent catheterization or invasive procedure.
Dx Duplex ultrasonography is the imaging modality of choice and will confirm pulsatile flow that communicates with the arterial lumen through a narrow neck.
Tx Tx depends on the size of the aneurysmal neck. Neck sizes less than 5 mm may be amenable to ultrasound-guided injection of thrombin to thrombose the pseudoaneurysm. Very small pseudoaneurysms may clot without intervention. Larger pseudoaneurysms require surgery to close the hole in the artery. See Sabiston 65, Becker 38.


















Abscess
PΦ An abscess is a walled-off collection of pus.
TP It presents as an erythematous, tender mass. Patients frequently have a hx of previous abscesses or diabetes mellitus.
Dx Dx is made by clinical examination. Needle aspiration can confirm purulence in equivocal cases. Ultrasonography will show fluid inside the abscess cavity.
Tx Tx is by incision and drainage.



ZEBRA ZONE



a. A varicocele is an engorgement of the venous plexus of the scrotum or inguinal canal. It may lead to infertility and may be either surgically repaired or watched conservatively. See Sabiston 77.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Groin Mass in a 68-Year-Old Male (Case 5)

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