Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 96 Emergency (2014); 2 (2): 96-97 CASE REPORT A 55-Year Old Man with Acute Painful Flank Mass, a Case Report Aida Alavi-Moghaddam1, Reza Shirvani2, Mahmoud Yousefifard3, Mostafa Alavi-Moghaddam2* 1. Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2. Department of Emergency Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3. Department of Physiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran Abstract Lumbar hernias (LH) accounts for less than 1.5% of total hernia incidence. It can occur in two separate triangular areas of the flank. About 300 cases have been reported in the literature. Here, we report a 55-year old man with acute painful left side flank mass and final diagnosis of LH. The mass was appeared about three hours before ad- mission and his pain was slight at first but became more severe gradually. He had stable vital sign and the only positive finding on his physical examination was the sphere shape, firm, mobile, and mild tender mass at his left flank. Key words: Hernia; flank pain; case report Cite this article as: Alavi-Moghaddam A, Shirvani R, Yousefifard M, Alavi-Moghaddam M. A 55-year old man with acute painful flank mass, a case report. Emergency. 2014;2(2):96-7. Introduction:1 umbar hernias (LH) are rare; about 300 cases have been reported. It can occur in two separate triangular areas of the flank (1-3). The superior triangle (Grynfeltt's lumbar triangle) is bound by the 12th rib superiorly, the internal oblique muscle inferi- orly, and the sacrospinous muscles medially. The inferi- or triangle (Petit's lumbar triangle) is bound by the la- tissimus dorsi muscle posteriorly, the external oblique muscle anteriorly, and the iliac crest inferiorly (4). LHs are more common on the left side. This may be because the liver pushes the right kidney inferiorly in develop- ment, leading to the protection of the lumbar triangles (5). LH may contain a number of intra or retroperitone- al structures including large intestine, small intestine, stomach, kidney, spleen, and mesentery omentum. 25% of all LHs are secondary acquired that may be caused by blunt-penetrating or crushing trauma; fractures of the iliac crest; surgical lesion; hepatic abscesses; infection in pelvic bones, and ribs or lumbodorsal fascia (1) . In- cisional hernias develop in 3.8%-11.5% of cases after abdominal –surgical procedures (6). The incidence de- pends on a number of risk factors including old age, sex, obesity, suture type and wound infection. Here, we re- port a 55-year old man with acute painful left side flank mass. *Corresponding Author: Mostafa Alavi-Moghaddam; Imam Hosein Hospital, Shahid Madani Ave, Tehran, Iran. Phone/Fax: +989125597918. Email: mosalavi@yahoo.com Received: 9 February 2014; Accepted: 21 March 2014 Case report: A 55-year-old homeless man came to the emergency department (ED) with pain and a mass in his left flank. The patient was awake and oriented. This mass was appeared about three hours before admission and his flank pain was slight at first but became more severe gradually. On admission, he had 18 per minute respira- tory rate, 88 per minute pulse rate, 110/80 mmHg blood pressure, 90% O2 saturation in room air, and 37°C auxiliary temperature. The pain score was about 9 to 10 according to visual analog scale (VAS). The only positive finding on physical examination was the sphere shaped, firm, mobile, and mild tender mass at his left flank (Figure 1). There was a 5 cm scar on this site be- cause of previous penetrating trauma injury due to a motor vehicle collision. There was an abdominal wall defect about 8 cm in diameter and bowel loop was trapped in the neck of hernia sac on computed tomog- raphy (CT) (Figure 2). As a result, a Petit's triangle LH was diagnosed. Surgery was performed immediately by diagnosis of strangulated LH. Finally, the report of sur- gery finding confirmed diagnosis. Discussion: LH accounts for less than 1.5% of the total hernia inci- dence (7). The inferior lumbar hernia is less common because of attachment of external oblique and latissmus dorsi to the iliac crest. Lumbar hernia could be divided into two groups congenital and acquired (8). Congenital LH accounts for 20% of all LHs. Congenital LH usually could be seen in superior lumbar triangle. Complica- L This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 97 Alavi-Moghaddam et al tions ofLH include irreducibility, incarceration and strangulation (9). In LH symptomatology limited to lower back pain. In less than 10% of cases the onset is acute with bowel obstruction (10). Treatment depends on the size and type of hernia. If the defect is small, it can be closed with continuous polypropylene. For large defect, preperitoneal meshplasty is the best treatment. Laparoscopic repair has been used in different reports with less pain and good functional result (11). Motor vehicle accidents are the most common cause of post- traumatic LHs (1, 4). If a LH is found after a motor vehi- cle accident, it is critical to assume that the patient has other intra-abdominal injuries. These patients should undergo urgent laparotomy because more than 60% of them will have major intra-abdominal injuries. Acknowledgments: We would like to thank Mohammad Reza Sohrabi for his valuable helps. Also, thanks to the patient's permis- sion to use photos. Conflict of interest: None Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu- tion based on recommendations of the International Committee of Medical Journal Editors. References: 1. Abrahamson J. Postoperative ventral abdominal hernia. In: Zinner MJ, Schwartz SI, editors. Hernias. 10 ed. Stanford: Appleton and Lange; 1990. p. 479–580. 2. Astarcioglu H, Sokmen S, Atila K, Karademir S. Incarcerated inferior lumbar (Petit's) hernia. Hernia. 2003;7(3):158-60. 3. Baratloo A, Safari S, Rouhipour A, et al. The Risk of Venous Thromboembolism with Different Generation of Oral Contra- ceptives; a Systematic Review and Meta-Analysis. Emergency. 2014;2(1):1-11. 4. Bohn D. Congenital diaphragmatic hernia. Am J Respir Crit Care Med. 2002;166(7):911-5. 5. Bucknall T, Cox P, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J (Clin Res Ed). 1982;284(6320):931. 6. Dinger J, Assmann A, Möhner S, Do Minh T. Risk of venous thromboembolism and the use of dienogest and drospirenone containing oral contraceptives: results from a German case- control study. J Fam Plann Reprod Health Care. 2010;36(3): 123-9. 7. Gronich N, Lavi I, Rennert G. Higher risk of venous thrombosis associated with drospirenone-containing oral contraceptives: a population-based cohort study. Can Med Assoc J. 2011;183(18):E1319-E25. 8. Hegarty M, Bryer J, Angorn I, Baker L. Delayed presentation of traumatic diaphragmatic hernia. Ann Surg. 1978;188(2): 229. 9. Le Neel J, Sartre J, Borde L, Guiberteau B, Bourseau J. Lumbar hernias in adults. Apropos of 4 cases and review of the literature. J Chir (Paris). 1993;130(10):397-402. [French]. 10. Manzoli L, De Vito C, Marzuillo C, Boccia A, Villari P. Oral Contraceptives and Venous Thromboembolism. Drug Saf. 2012;35(3):191-205. 11. Wiechmann RJ, Ferguson MK, Naunheim KS, et al. Laparoscopic management of giant paraesophageal hernia- tion. Ann Thorac Surg. 2001;71(4):1080-7. Figure 1: The Patient’s left flank mass  Figure 2: Abdominal computed tomography of pa- tients