Hrev_master Emergency Care Journal 2023; volume 19:11926 [Emergency Care Journal 2023; 19:11926] [page 46] A small lump in the abdomen Massimo Barakat Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Bologna, Italy Question Given the patient’s history and ultrasound image, which is the cor- rect diagnosis? A. Umbilical vein recanalization B. Falciform ligament thrombosis C. Herniation of the round ligament of the liver through the anterior abdominal wall with hyperemia in surrounding subcutaneous adipose tissue D. Arteriovenous malformation of the anterior abdominal wall Correspondence: Massimo Barakat, Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, via Pietro Albertoni 15, Bologna, Italy. Tel.: +39.0512.144327 E-mail: massimo.barakat@gmail.com Key words: epigastric hernia; round ligament of the liver; ultrasound; computed tomography. Conflicts of interest: the author declares no conflict of interest. Availability of data and materials: all data and materials are included in this published article. Ethics approval and consent to participate: as this was a descriptive case report and data were collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Informed consent: the patient provided consent for the access to medical records at the time of admission. Received: 6 October 2023. Accepted: 17 October 2023. Early view: 20 October 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2023; 19:11926 doi:10.4081/ecj.2023.11926 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. A 20-year-old man presented to the emergency department with a small painful swelling located in the midline of the epigastric region. His medical history included asthma and extramucosal pyloromyotomy for hypertrophic pyloric stenosis when he was a baby. His vital signs were normal. Abdominal ultrasound (US) showed a small hypoechoic formation located in the subcuta- neous adipose tissue that penetrated into the abdominal cavity through an orifice of about 7 mm in the linea alba. Non -co mmerc ial us e o nly Images in Emergency [page 47] [Emergency Care Journal 2023; 19:11926] Answer Herniation of the round ligament of the liver through the ante- rior abdominal wall with hyperemia in surrounding subcutaneous adipose tissue is the correct answer, as confirmed by an abdominal contrast enhanced computed tomography scan (Figure 1 A, B). The patient was promptly discharged from hospital with symptomatic therapy alone (Ibuprofen, 600 mg daily for six days), avoiding surgery. Complete pain relief was achieved within few days and the patient is still doing well. Abdominal herniation is a protrusion of part of its content from the abdominal cavity through a normal or abnormal aperture or from wall weakness.1 Diagnosis is usually made at physical exam- ination; however, clinical diagnosis can be difficult, especially in patients with pain. In these cases, abdominal imaging may be the first clue to correct diagnosis.2,3 Abdominal US and CT scan can define hernial content, distinguish it from other abdominal wall masses (such as hematomas, abscesses, sebaceous cysts, haeman- giomas, arteriovenous malformations, and other soft tissue tumours), and detect signs of complications within the hernia sac, i.e., incarceration and strangulation, which require an urgent surgi- cal evaluation.2,4 Epigastric hernias occur on the linea alba between the xiphoid process and umbilicus.2 These hernias contain the fal- ciform ligament in only 2.4% of cases.5 Considering that abdomi- nal wall hernias represent the second most common indication for surgery after acute appendicitis in Western countries,6 a prompt imaging recognition of this rare epigastric hernia may allow a con- servative management. For these reasons emergency physicians should know this unusual condition in order to avoid unnecessary surgical treatment. References 1. Mathieu D, Luciani A; GERMAD Group. Internal abdominal herniations. AJR Am J Roentgenol 2004;183:397-404. 2. Lassandro F, Iasiello F, Pizza NL, et al. Abdominal hernias: Radiological features. World J Gastrointest Endosc 2011;3:110-7. 3. Aguirre DA, Casola G, Sirlin C. Abdominal wall hernias: MDCT findings. AJR Am J Roentgenol 2004;183:681-90. 4. Ballard DH, Mazaheri P, Oppenheimer DC, et al. Imaging of Abdominal Wall Masses, Masslike Lesions, and Diffuse Processes. Radiographics 2020;40:684-706. 5. Saito A, Haruta H, Kumagai Y, et al. Single incision laparoscopy surgery repair of a linea alba hernia. Jichi Med Univ J 2019;42:15-18. 6. Madoz A, Franpas E, D’Alincourt A, Perret C, Laute F, Liebault B, Dupas B. Imagerie des hernies pariétale abdomi- nales. Elsevier Masson SAS 2007;33:A39. Figure 1. Oblique axial (A) and oblique sagittal (B) abdominal contrast enhanced computed tomography scan.Non -co mmerc ial us e o nly