When Minutes Matter: Point-of-Care Ultrasound Unmasking a Clinically Occult Hernia in a Toddler

Supraumbilical hernias are an uncommon cause of pediatric small bowel obstruction and may remain clinically occult until acute incarceration occurs. The absence of a visible or palpable abdominal wall defect can delay diagnosis, making early recognition of bowel obstruction essential to prevent ischemic complications. We report the case of a 27-month-old previously healthy girl who presented with a one-day history of progressively worsening abdominal pain and eight episodes of non-bilious vomiting following a recent parainfluenza infection. Physical examination demonstrated mild abdominal distension with periumbilical and suprapubic tenderness, without a visible or palpable abdominal wall hernia. Point-of-care ultrasound performed in the emergency department revealed markedly dilated fluid-filled small bowel loops and free intraperitoneal fluid, raising concern for mechanical small bowel obstruction despite inconclusive examination findings. Urgent surgical consultation was obtained, and subsequent abdominal radiography and computed tomography supported the diagnosis of high-grade small bowel obstruction. Exploratory laparotomy identified a tightly incarcerated supraumbilical hernia causing high-grade obstruction with early ischemic changes but no bowel necrosis. Reduction of the incarcerated bowel restored viability, and no bowel resection was required. The patient had an uncomplicated postoperative recovery and was discharged on the third postoperative day. This case highlights the diagnostic value of point-of-care ultrasound in the early evaluation of pediatric small bowel obstruction when physical examination findings are inconclusive. It also emphasizes that an occult supraumbilical hernia may present acutely with bowel obstruction despite the absence of previous symptoms or an obvious abdominal wall defect. Early recognition and prompt surgical intervention were essential in preventing bowel necrosis and achieving a favorable outcome.