Rosen & Barkin's 5-Minute Emergency Medicine Consult (339 page)

• 572.4 Hepatorenal syndrome
  
• 997.49 Other digestive system complications
  

BASICS

• Protrusion of bodily structure or organ through a defect in tissues normally containing it.
  
• Classified as external (hernia protrudes visibly to outside), internal (herniated contents occur within body cavity), or interparietal (hernial sac contained within abdominal wall)
  
• Abdominal wall hernia due to weakness or disruption of fibromuscular layer of abdominal wall
  
• “Groin” hernias include femoral, direct, and indirect inguinal hernias
  
• “Ventral” hernias include epigastric, umbilical, and spigelian hernias
  
• External:
  
  • Indirect inguinal hernia:
    
    • Results from persistent process vaginalis
      
    • Peritoneal contents herniate through internal ring
      
    • Right side more common than left
      
    • 27% lifetime risk of repair for men; 3% for women
      
  • Direct inguinal hernia:
    
    • Due to weakness or defect in transversalis area in Hesselbach triangle:
      
    • Inguinal ligament inferiorly
      
    • Inferior epigastric vessels laterally
      
    • Lateral border of rectus abdominus medially
      
  • Incisional hernia:
    
    • Resultant breakdown of previous surgical fascial closure
      
  • Femoral hernia:
    
    • Peritoneum herniates into femoral canal beneath inguinal ligament.
      
    • Incarceration frequent due to protrusion through small orifice
      
    • Internal: Diaphragmatic, hernias from mesenteric/omental tears, foramen of Winslow
      
• Other hernias:
  
  • Obturator (pelvic) hernia:
    
    • Passes through obturator membrane and exits beneath pectineal muscle
      
  • Epigastric hernia:
    
    • Midline between xiphoid and umbilicus
      
  • Spigelian hernia:
    
    • Protrusion through oblique fascia lateral to rectus abdominus muscle
      
  • Lumbar hernia:
    
    • Occur in superior and inferior lumbar triangle of posterior abdominal wall (incarcerate in 25% cases)
      
    • Usually middle-aged men, chronic low back pain with palpable mass
      
  • Umbilical hernia:
    
    • Congenital failure of umbilical ring to close
      
    • Protrusion through fibromuscular umbilical ring/umbilicus
      
    • Often incarcerate in adults, although rarely in infants (often spontaneously close)
      
    • 20–45% recurrence rate
      

• Hernia repair (herniorrhaphy) extremely common general surgical procedure (>750,000 performed in US annually)
  
• Prevalence: 5% of population
  
• Groin and femoral hernias account for 85% of hernias:
  
  • Umbilical and incisional hernias account for additional 10%
    

• Reducible hernia:
  
  • Protruding structures can be returned to abdominal cavity
    
• Incarcerated hernia:
  
  • Contents of hernia cannot be manipulated back into abdominal cavity
    
• Strangulated hernia:
  
  • Vascular compromise of entrapped bowel contained within hernia leading to ischemia and gangrene (skin color changes may be apparent)
    
  • Higher risk in hernias with small openings and large sacs
    
  • Signs and symptoms of bowel obstruction or ischemia may occur (nausea/vomiting, fever, leukocytosis)
    

DIAGNOSIS

• Pain and swelling:
  
  • Localized to region of hernia
    
• Persistent pain, vomiting, fever may indicate:
  
  • Incarceration
    
  • Strangulation
    
  • Bowel obstruction
    

• Vital signs:
  
  • Frequently normal
    
  • Tachycardia with pain, dehydration, infection
    
  • Hypotension with dehydration, strangulation, infection/sepsis
    
  • Fever with infection/sepsis
    
  • Skin color changes with strangulation
    
• Inguinal hernia:
  
  • Pain:
    
    • Localized to inguinal region
      
    • Exacerbated by straining/positional changes
      
    • Relieved by rest
      
  • Swelling:
    
    • Males: Bulge in scrotum
      
    • Females: Bulge immediately inferior to inguinal ligament or in labia
      
  • Swelling of spermatic cord, scrotum, or testes
    
  • Valsalva maneuver performed with finger directed toward internal ring—may allow hernia sac to descend against finger
    
• Femoral hernia:
  
  • Pain/swelling:
    
    • Localized to femoral orifice inferior to inguinal ligament
      
• Incisional hernia:
  
  • Pain/swelling:
    
    • Localized to previous incision/scar
      
• Obturator hernia:
  
  • Nonspecific abdominal pain
    
  • Intermittent intestinal obstruction
    
  • Weight loss
    
  • Pain:
    
    • Owing to pressure on obturator nerve from hernia (Howship–Romberg sign)
      
    • Along medial thigh
      
    • Radiating to hip
      
    • Relieved with thigh flexion
      
    • Exacerbated by hip extension, adduction, or external rotation
      
• Spigelian hernia:
  
  • Abdominal pain/mass along anterior abdominal wall
    
  • Increased pain with maneuvers increasing intra-abdominal pressure
    
  • Intermittent bowel obstruction
    
  • Palpable mass along spigelian line:
    
    • Convex line extending from costal arch to pubic tubercle along lateral edge of rectus muscle
      

• Diagnosis often difficult:
  
  • Parents describe bulge in inguinal area often no longer present at time of exam.
    
  • Incarcerated hernias may present with irritability, abdominal pain, or intermittent vomiting.
    
• Incidence of incarceration/strangulation is 10–20%:
  
  • >50% in patients younger than 6 mo of age
    
  • Incidence of incarceration higher in girls than boys
    
• Umbilical hernias:
  
  • Strangulation and incarceration rare
    
  • Most close spontaneously
    
  • Most surgeons will delay closure until 4 yr of age, although timing is controversial
    
• Inguinal hernias (consider hydrocele):
  
  • If hydrocele, neck narrows at external inguinal canal without extension into inguinal canal
    

• Hernias uncommon during pregnancy, manifesting before or during
  
• Inguinal hernia: 1:1,000–3,000 incidence, 75% occurring in multiparas
  
• Recognition of emergent situations (incarceration, strangulation) may be a diagnostic and management challenge
  
• No consensus exists regarding treatment of unreducible hernia during pregnancy; complications during pregnancy may outweigh elective hernioplasty and emergent surgical consultation recommended
  

• Higher risk of bowel resection if older than 65 years of age with incarcerated hernias
  
• Higher postoperative pulmonary and cardiovascular complications
  

Careful history and physical exam:

• Palpate inguinal/femoral area for tenderness/masses.
  
• Attempt exam with the patient standing or straining (Valsalva maneuver) if hernia not obvious.
  
• Pelvic exam in women to evaluate gynecologic etiologies of groin pain
  

• CBC:
  
  • Leukocytosis with strangulation
    
• Electrolytes, BUN/creatinine, glucose:
  
  • If vomiting/dehydration
    
• Urinalysis:
  
  • Genitourinary causes of groin pain
    

• Plain abdominal radiographs:
  
  • Obstructive bowel pattern with incarceration or strangulation
    
• US:
  
  • For identifying masses in groin or abdominal wall
    
  • May be difficult in obese patients
    
• CT:
  
  • To diagnose obturator or spigelian hernia
    
  • Consider in symptomatic patients in whom body habitus precludes adequate physical exam or US study
    

• Hydrocele
  
• Varicocele
  
• Lymphadenitis
  
• Testicular torsion
  
• Testicular tumor
  
• Undescended testis
  
• Renal calculi
  
• UTI
  
• Ovarian torsion
  
• Lymphogranuloma venereum
  

TREATMENT

• 0.9% NS IV fluid resuscitation for dehydration, bowel strangulation, obstruction, or sepsis:
  
  • Adults: 1 L bolus
    
  • Peds: 20 mL/kg bolus
    

• Incarcerated or strangulated hernias:
  
  • IVFs
    
  • Nasogastric tube (NGT)
    
  • Surgical consultation
    
  • Preoperative broad-spectrum antibiotics for strangulated hernia (controversial)
    
• Hernia reduction procedure:
  
  • IV sedation (benzodiazepines) and analgesia (opiates) if necessary
    
  • Place patient in Trendelenburg position.
    
  • For spontaneous reduction, allow 20–30 min
    
  • For manual reduction:
    
    • Place constant, gentle pressure on hernia.
      
    • For inguinal hernias, achieve reduction by putting fingers of 1 hand on internal ring while gently pulling then pressing on hernia distal to external ring.
      
  • Obtain surgical consultation if reduction is unsuccessful after 1 or 2 attempts.
    
  • Contraindications to reduction include:
    
    • Fever
      
    • Leukocytosis
      
    • Signs of strangulation
      
  • Complications:
    
    • Introduction of strangulated bowel into abdomen
      
    • Further ischemia/necrosis occurs with no clinical improvement.
      
  • Reduction in girls may be more difficult if ovary encased within hernia.