Ultrasound Case

A 15 y/o F with trisomy 21 and morbid obesity presented with abdominal pain associated with a couple episodes of NBNB emesis.  Mother stated that there was a "knot on her stomach" as the source of the pain.  When the patient was asked where it hurt, she pointed to an area on her R mid-abdomen which was quite firm and about 1-2 cm in size; no obvious swelling could be appreciated due to the patient's body habitus.  There was no overlying erythema and no history of fevers.  A bedside ultrasound was performed using the linear probe for superficial structures:

These images demonstrate (beginning from the top of the image) normal skin, subcutaneous tissue, followed by bright linear peritoneum which is interrupted by a hypoechoic, well-demarcated mass containing some echogenic material.  Looking closely at the margins of the mass, one can appreciate several layers to the wall, suggesting that this may be something other than an abscess.  The diagnosis of a possible ventral abdominal hernia was communicated to the primary providers who consulted Surgery; their recommendation included a CT scan which confirmed the presence of a ventral abdominal hernia  measuring 3.6 x 3.1 mm just to the right and superior of the umbilicus; it contained omental fat and no bowel.  The surgical team successfully reduced the hernia in the ED and patient was discharged home.