A 90-year-old woman with a history of hypertension and severe dementia experienced epigastric pain and vomiting after dinner. Her family sought care from a primary care physician. She was suspected to have a myocardial infarction because of her ambiguous complaints of epigastric pain and abnormal portable electrocardiogram findings. She was immediately transferred to the emergency department of our hospital by ambulance. She was initially seen by a cardiologist, who ruled-out the presence of ischemic heart disease. She was then referred to the general medicine department. She only complained of nausea and epigastric discomfort without abdominal pain. On physical examination, her vital signs were stable. Her abdomen was soft and flat, and her bowel sounds were present but weak. On palpation, she had tenderness on pressure in the lower abdomen without peritoneal irritability. Peripheral blood analysis revealed a white blood cell count of 10,200/mul without a left shift. Her C-reactive protein level was 0.10 mg/dl. Her abdominal X-ray showed a dilatation of the small intestine in the left lower abdomen without air-fluid levels. Dilatation of the colon was not detected. Although she had no history of previous abdominal surgery, we could not rule-out the possibility of mild mechanical ileus, despite these minor findings.
While in the hospital, she was not allowed to eat, and intravenous fluids were administered. However, she continued to have abdominal tenderness in the lower abdomen. Furthermore, she expelled no gas or stool after her admission. On the third hospital day, a follow-up abdominal X-ray showed increased small intestinal dilatation and air-fluid levels (Figure 1A). For the first time after admission, she was examined by abdominal CT. Although it also showed intestinal dilatation similar to her abdominal X-ray, the enhancement of the intestinal wall was good, which meant that circulation in the intestinal wall was not impaired. In addition, there was no elevation of CK or LDH in her blood test result. We installed an ileus tube, and her symptoms improved dramatically. Radiological enteroclysis showed several apparently constricted areas, which we considered to be the cause of her ileus. We explored the cause of the constriction, considering intestinal tuberculosis or Crohn's disease. However, the level of QuantiFERON TB-2G was normal. There was no abnormal finding in her gastrointestinal endoscopy or total colon endoscopy. When we reviewed the abdominal CT scan, we found a slight obturator hernia in her right obturator canal, which contained only a part of the small intestine wall (Figure 1B), called the Richter type. Although OH requires surgery, we selected the conservative treatment because her condition had already been improving without surgery. Furthermore, we thought that she could not be placed at rest after the operation and had many risks for surgery due to her old age and dementia, because of which her family wanted to avoid preventive surgery. She was discharged on day 52 of hospitalization without having undergone surgery. No recurrence of the hernia was noted during the 6-month follow-up.