Ruptured abdominal aortic aneurysm is a great masquerader that can present in a variety of clinical symptoms and signs. This is a case of ruptured abdominal aortic aneurysm that presented as a strangulated left inguinal hernia. The diagnosis of an inguinal hernia, be it complicated or uncomplicated is often simple and straight forward. Rarely this simple presentation may be the external manifestation of a distant pathology, which is in communication with the inguinal canal through its anatomic relationship. . Familiarity with the surgical emergencies that can mimic or present as simple irreducible hernia would enable a rapid diagnosis to be made with timely subsequent intervention. During exploration the presence of haematoma with in the cord warrants further laparotomy. Contrast enhanced CT scan is recommended for all dubious cases at an early stage. Introduction Ruptured abdominal aortic aneurysm is a great masquerader that can present in a variety of clinical symptoms and signs. This is a case of ruptured abdominal aortic aneurysm that presented as a strangulated left inguinal hernia. To the best of our knowledge there are only 15 such case reports. In all those, the patient was either anaemic, hypotensive or had intraoperative active bleeding in inguinal canal from retro peritoneum. This haemodynamically normal patient presented with acute left groin pain, irreducible left inguinal swelling and vomiting with normal hemoglobin and very high inflammatory markers. Case History A 67-year-old gentleman presented to the accident and emergency department at 4am with left groin pain, vomiting, and bloatedness of 7 hours duration. He had a history of intermittent left groin pain for the past 5 weeks. He had opened the bowels the day before, which was normal. Apart from being asthmatic there was no significant past medical or surgical illness. On examination he was afebrile, alert, oriented with a normal heart rate of 96/mt and a blood pressure of 130/94.On abdominal examination there was generalised tenderness with rigidity on the left side of the abdomen with sluggish bowel sounds .A 4x4 cm non-pulsatile non reducible tender lump was palpated in left groin. No pulsatile mass was palpated in the abdomen. All peripheral pulses were felt in good volume with no brachio - femoral delay. Per rectal examination was normal.His blood tests on admission were: hemoglobin 13.2 gm%, white cell count 21X109/l, amylase 52iu/l, C reactive protein 25 mg/l with normal electrolytes, renal and liver function tests. The x ray of chest, abdomen and ECG were normal. With the clinical diagnosis of a strangulated left inguinal hernia he underwent exploration of left inguinal region that showed haematoma of the spermatic cord from deep ring to root of testes with blood seemed to be seeping into the tunica albugenia. There was neither fresh bleeding nor any evidence of hernia. Post operatively (12 hours after admission) he was afebrile with a blood pressure of 124/80, heart rate of 118 and oxygen saturation of 98% on air. Six hours after surgery he was afebrile with blood pressure of 120/80, heart rate of 110 and oxygen saturation of 98% on air. Post operatively he had contrast enhanced CT scan of the abdomen which showed a leaking infrarenal abdominal aortic aneurysm
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