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The chicken or the egg story: which came first, epigastric hernia in a patient with huge urinary bladder stone
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  1. Abdul Majid Wani1,
  2. Waleed Mohd Hussain1,
  3. Mohamad Ibrahim Fatani1,
  4. Sadeya Hanif Raja1,
  5. Khaled Shawkat Ali2,
  6. Ashraf Basraheel1,
  7. Mubeena Akhtar1,
  8. Mazen G Bafaraj3
  1. 1
    Hera General Hospital, Medicine, 4a/201, Makkah, 21955, Saudi Arabia
  2. 2
    Hera General Hospital, Makkah, 21955, Saudi Arabia
  3. 3
    Umul Qurah University, Makkah, 21955, Saudi Arabia
  1. Abdul Majid Wani, dr_wani_majid{at}yahoo.co.in

https://doi.org/10.1136/bcr.09.2009.2236

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    A 78-year-old man presented with a huge abdominal swelling of 3 years duration. The swelling had progressively increased in size, especially over the last year. The patient also gave a history of dysuria and increased frequency of micturation of 8 years duration, which was attributed to prostatism. The patient had been receiving intermittent symptomatic treatment, and had been taking warfarin 3 mg for the last 6 years for paroxysmal atrial fibrillation. Examination revealed a large epigastric hernia (fig 1) with bowel loops as its content. Chest and cardiovascular examination including heart sounds was normal. Digital rectal examination was normal for prostrate, and blood counts, renal and liver function tests were normal. Urine analysis showed pus cells too numerous to count. Serum uric acid levels were 11.6 mg/dl (normal range up to 7 mg/dl) mg/dl. Plain x ray of the abdomen and ultrasonography were normal. A review of the patient’s records revealed previously normal uric acid levels (4.2 mg/dl). An investigation for hyperurecaemia was initiated, meanwhile the patient was given ciprofloxacin 500 mg twice a day. A CT scan of the abdomen revealed a large 3.9×3.6 cm urinary bladder stone (fig 2) and a large epigastric hernia filled with colonic loops (fig 3). A review of the literature for causes of hyperurecaemia revealed warfarin-induced hyperurecaemia and gout.1,2

    Figure 1
    Figure 1

    Large epigastric hernia.

    Figure 2
    Figure 2

    Non-contrast CT scan showing a typical uric acid stone in the urinary bladder.

    Figure 3
    Figure 3

    Contrast CT scan showing bowel loops as the contents of the huge epigastric hernia.

    The patient was sent to a urologist for further investigation and management of his bladder stone, which was removed and analysed, and shown to be composed of urate. Warfarin was stopped as the patient had no evidence of cardiac thrombus and was in sinus rhythm. Allopurinol 300 mg/day was given in addition to advice to maintain a urine output greater than 2 litres/day.

    Long-term warfarin use can lead to hyperurecaemia and urolithiasis. Urinary bladder stones can also be the cause of symptoms mimicking prostatism in older patients. Chronic straining while urinating and a rise in intra-abdominal pressure can lead to an increase in size of small epigastric hernias, with chances of strangulation. Regarding the epigastric hernia in our patient, there is no other predisposing factor than straining on urination, which has been the case for some time. However, the increase in size of the hernia can be explained as secondary to straining, but not its origin. The epigastric hernia was primary (M2) as per the classification of the European Hernia Society.3 There is no previous report of a urinary bladder stone causing epigastric hernia. Thus, this is the story of the “chicken and the egg”: which came first, the epigastric hernia or the urinary bladder stone?

    Learning points

    • The symptoms of prostatism are not always due to benign prostatic hyperplasia.

    • A urinary bladder stone can mimic prostatic symptoms and can be missed if radiolucent on routine x ray.

    • A urate stone may be the result of warfarin-induced hyperurecaemia.

    • In this case, an epigastric hernia is reported in association with a huge urate urinary bladder stone.

    Acknowledgments

    We are grateful for the support of Miss Mecciya Hadi Majrooshi (secretary) and Mrs Manal Karima, director of Postgraduate Education.

    REFERENCES

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      . Classification of primary and incisional abdominal wall hernias. Hernia 2009; 13: 407–14.
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    Footnotes

    • Competing interests: None.

    • Patient consent: Patient/guardian consent was obtained for publication.