My baby has a “mass!”

A 38 day old term male with history of left sided undescended testicle presented with fussiness and bulging of the left inguinal area x 2 hours.
You obtain the following clip and images:

 

 

ANSWER:

Inguinal Hernia.
The US revealed bowel (with peristalsis) seen within the left inguinal canal. Blood flow was unable to be confirmed due to patient movement. Emergent surgical consultation was obtained due to concern of incarcerated hernia. The patient later was found to have spontaneously reduced when he underwent formal ultrasound and was schedule for out patient follow up and surgery planning.
More on Inguinal Hernias
-Ultrasound is the recommended modality of initial imaging to evaluate inguinal hernias. It has a high sensitivity and specificity and can easily distinguish hernia from other pathologies
-Apply color doppler flow to the image- if flow is not present in the bowel there is an increased likelihood/concern for strangulation.
-Incarceration denotes a hernia that cannot be reduced by manipulation. An incarcerated hernia may or may not be strangulated.
-The inguinal canal is a passage through the abdominal wall though which the spermatic cord passes from the abdomen into the scrotum in males and the round ligament passes to the labia majora in females.
-Inguinal hernias occur in 1-5% of all newborns and 9-11% of premature infants.
-Incarceration usually occurs in infants less than 1 year (14-31%) and is the presenting sign in up to 65% of cases.
-Symptoms of incarcerated hernia include a fussy, irritable crying infant. Vomiting and abdominal dissension may be present. Physical exam can usually make the diagnosis: firm, non-reducible inguinal mass that is usually tender and edematous.
References
Clatworthy WH Jr, Thompson AG. Incarcerated and strangulated inguinal hernia in infants: a preventable risk. J Am Med Assoc. 1954;154:123.
Kapur P, City MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am.1998; 45:773.
Puri P, Guiney EJ, O’Donnell B. Inguinal hernia in infants: the fate of the testis following incarceration. J Pediatr Surg. 1984;19:44. 
Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to elective repair. J Pediatr Surg. 1993;23:582.
Robinson A, Light D, Kasmin A et al. A systematic review and metanalysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc. 2013;27(1):11.
Robinson A, Light D, Nice C. Meta-analysis of sonography in the diagnosis of inguinal hernias. J Ultrasound Med. 2013;32(2):339.
Laurie Malia

Laurie Malia

Assistant Professor of Emergency Medicine and Pediatrics,Pediatric Emergency Medicine Ultrasound Fellow at Morgan Stanley Children's Hospital /Columbia University Medical Center Department of Emergency Medicine
PEM doc; POCUS; Pediatrics; Healthcare equality
Laurie Malia

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Laurie Malia

Laurie Malia

PEM doc; POCUS; Pediatrics; Healthcare equality