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Strangulated Hernia

Hernia Strangulate

Upon protrusion through the hernial orifice, blood vessels of a hernia may become constricted. This condition is referred to as strangulated hernia; it may be associated with gangrenous necrosis of affected tissues and life-threatening complications.


Presentation

Strangulation may occur within distinct periods of time after the initial protrusion of viscera [8]. It should be noted that a considerable subset of individuals suffering from hernia remains asymptomatic until strangulation occurs. Rarely, SH is observed in patients previously diagnosed with hernia, who have been recommended watchful waiting or opted against elective surgery.

Most commonly, the hernial sac corresponds to a visible and palpable bulge, but this may not be the case in obese SH patients. The hernial sac and surrounding tissues are often erythematous and extremely tender, and patients claim intensifying discomfort when adopting a determined posture or coughing. In SH patients, intense pain usually leads to the diagnosis of acute abdomen. As per definition, SH is not manually reducible [7]. With regards to hernia contents, functional impairment of protruded viscera usually manifest as the inability to pass stools or gasses. Bowel sounds may be decreased or absent [9]. Compromise of the urogenital tract may cause micturition problems. Diaphragmatic SH may also be associated with respiratory symptoms. Any strangulated tissue may undergo gangrenous necrosis and serve as a source of toxins released upon cell death. If portions of the intestines are affected, microorganisms may pass the mucosal barrier and cause sepsis. Patients may thus present with systemic symptoms such as general malaise, fever, tachycardia, nausea, and vomiting.

Inguinal Mass
  • Differential Diagnosis: Not all inguinal masses are hernias.[fastbleep.com]
  • Inguinal masses that resemble hernias may be the result of adenopathy (infectious or malignant), an ectopic testis, or lipoma. These masses are solid and are not reducible. A scrotal mass may be a varicocele, hydrocele, or testicular tumor.[msdmanuals.com]
  • Cysts located in the inguinal canal are present as inguinal mass, while those occurring below in the outer ring are usually pubic masses. Cysts of the round ligament are round, solid masses with clear boundaries, with a cystic feeling.[ncbi.nlm.nih.gov]
Constipation
  • Obstruction to the fecal current accounts for the constipation, vomiting, tympanites and the presence of indican in the urine. The severity Full Text[jamanetwork.com]
  • Perhaps your son is just constipated. I would call the dr's office and ask about it. One option would be an enema, but I would talk to a dr or nurse and give some pear juice before that.[inspire.com]
  • History H/O Reducible inguinoscrotal swelling, H/O recent irreducibility, Pain (site, duration, character) Absolute Constipation, Abdominal Distention. Physical Examination Never try to manually reduce the strangulated hernia.[medicalopedia.org]
  • In another case, to which I was called in consultation, the old woman had stercoraceous vomiting for three or four days, with constipation. The hernia was femoral and irreducible.[neatorama.com]
  • Patients with an untreated strangulated hernia often experience nausea, vomiting, diarrhea or constipation. Such symptoms may indicate that the infection within the intestine has spread to additional regions of the body.[livestrong.com]
Abdominal Pain
  • He presented an abdominal pain of sudden onset 16 hours previously. The clinical examination, abdominal x-ray, and sonography were not helpful in the assessment of the diagnosis of internal hernia, which was evoked by the computed tomography.[ncbi.nlm.nih.gov]
  • Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself[nejm.org]
  • Generalized Abdominal Pain Generalized abdominal pain could also be a hernia symptom. This pain is serious, and results from internal abdominal organs, such as intestines, being pinched by the hernia, resulting in a compromised blood supply.[herniacenterlosangeles.com]
Epigastric Pain
  • CASE: A 58-year-old man with multiple medical comorbidities presented with acute epigastric pain and a right incarcerated inguinal hernia that was interpreted as showing bowel strangulation on computed tomography.[ncbi.nlm.nih.gov]
  • Patients are frequently fit young males who present with epigastric pain, which may be confused with peptic ulceration or biliary disease. Patients should be examined in both standing and lying positions.[surgwiki.com]
Abdominal Mass
  • Risk factors for the development of adult umbilical hernias include obesity, multiparity, ascites, and large abdominal masses. Adult umbilical hernias exhibit a female-to-male predominance and occur most commonly in those aged 50 to 70.[ahcmedia.com]
Dysphagia
  • Thus, there is a complete dysphagia. When the infringement of the stomach appears first vomiting, then to the stomach contents of vomit mixed with bile and blood.[medicineinfo.net]
Screaming
  • When she got to his groin he screamed when she touched him. There was a visible bulge in the groin and his testicles looked weird. They considered it a medical emergency.[inspire.com]
  • When caring for an ill patient whose presentation screams strangulation: resuscitate, resolve symptoms, and reach a surgeon. Imaging is likely not required.[ahcmedia.com]

Workup

Hernias are usually diagnosed clinically. Additional measures are rarely necessary, but sonography as well as plain radiography, computed tomography, or magnetic resonance imaging may be employed in selected cases [10] [11]. An appropriate technique should be chosen to allow the identification of the hernial orifice and hernial contents as well as the assessment of the protruded tissues condition.

Treatment

  • Awareness of SAM is important because, unlike vasculitides, immunosuppressive treatment may worsen the disease process.[ncbi.nlm.nih.gov]
  • Treatment is possible, however it is not only very different from treatment for a conventional hiatal hernia, when the treatment occurs is just as important as how it is handled.[hiatalherniacondition.com]
  • Depending on your treatment plan, you’ll need either local or general anesthesia during surgery. Open surgery is the preferred treatment for strangulated hernias. Laparoscopic surgical procedures have been tested as well.[healthline.com]

Prognosis

  • Septicemia carried the worst prognosis with 100% mortality. There were 7 death giving a mortality figure of 14%.[pjms.com.pk]
  • Prognosis If diagnosed early in childhood, the prognosis for children who have had a surgically repaired inguinal hernia is excellent.[healthofchildren.com]
  • Fevang BT, Fevang J, Lie SA, Soreide O, Svanes K, Viste A (2004) Long-term prognosis after operation for adhesive small bowel obstruction. Ann Surg 240:193–201 PubMed CrossRef Google Scholar 12.[link.springer.com]
  • Prognosis Congenital umbilical hernias rarely strangulate and are not treated; most resolve spontaneously within several years. Very large defects may be repaired electively after age 2 yr.[msdmanuals.com]

Etiology

  • BADAL KHAN, orthopedic resident surgeon at bolan medical complex hospital quetta Published on Oct 23, 2016 defination of hernia,epidemiology,etiology,parts of hernia,classification,clinical features,pathophysiology,predisposing factors and surgical management[slideshare.net]
  • Pathogenesis Etiology Failure of the endometrial release of prostaglandin at the proper time.[vetstream.com]
  • Ventral wall hernia subtypes and their etiologies, predisposing conditions, risk factors, and associated illnesses, are discussed below.[ahcmedia.com]
  • This is in contrast to indirect hernias which can occur at any age including the young, since their etiology includes a congenital component where the inguinal canal is left more patent (compared to individuals less susceptible to indirect hernias). [[en.m.wikipedia.org]
  • Etiology The etiology of indirect hernias is largely explainable in terms of the embryology of the groin and of testicular descent. An indirect inguinal hernia is a congenital hernia, regardless of the patient’s age.[emedicine.medscape.com]

Epidemiology

  • EPIDEMIOLOGY •INCIDENCE RATE OF STRANGULATED INGUINAL •HERNIA VARIES BETWEEN 0.29%AND 2.9% •MORTALITY RATE RANGES BETWEEN 2.6% TO 9% BUT A DELAY OF 12H INCREASE CHANCE OF INTESTINAL RESECTION RATE.[slideshare.net]
  • Abramson JH, Gofin J, Hopp C, Makler A (1978) The epidemiology of inguinal hernia: a survey in Western Jerusalem. J Epidemiol Community Healt 32: 59–67 Google Scholar 2.[link.springer.com]
  • Abdominal Hernias: Epidemiology. Medscape. . Accessed May 15, 2012. 2. Nicks BA, Askew K. Hernias: Epidemiology. Medscape. . Accessed May 15, 2012. 3. Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review.[surgery.wisc.edu]
  • Epidemiology Hernias comprise approximately 7% of all surgical outpatient visits. [ 1 ] Male:female ratio of groin hernias is 8:1. [ 2 ] Hernias and hydroceles occur in 1-3% of full-term infants. [ 3 ] In men, the incidence rises from 11 per 10,000 person-years[patient.info]
  • Epidemiology The incidence rate of strangulated inguinal hernia varies between 0.29 and 2.9 %.[intechopen.com]
Sex distribution
Age distribution

Pathophysiology

  • BADAL KHAN, orthopedic resident surgeon at bolan medical complex hospital quetta Published on Oct 23, 2016 defination of hernia,epidemiology,etiology,parts of hernia,classification,clinical features,pathophysiology,predisposing factors and surgical management[slideshare.net]
  • Hernia Pathophysiology Hernia Treatment Hernia Classification Types of Hernia[news-medical.net]
  • Pathophysiology See also Reproduction: management - female. Normal diestrus has an average duration of 16 days, and extends from ovulation to luteolysis.[vetstream.com]
  • Anatomy and pathophysiology of hernias.In:Fischer J, ed. Hernia:Master of techniques in surgery.Philadelphia, PA:Lippincott Williams & Wilkins; 2013:1-6.[crbard.jp]
  • Pathophysiology The majority of inguinal hernias are indirect hernias.[intechopen.com]

Prevention

  • Numerous deaths and cases of permanent disability occur in remote rural villages because common conditions requiring urgent surgery are neither prevented nor properly cared for.[ncbi.nlm.nih.gov]
  • Fever, which is a defense the immune system uses to prevent the spread of infection, may be present if you have a strangulated hernia.[livestrong.com]
  • If you have had a strangulated hernia treated in an emergency room, follow up with your medical doctor or specialist to see if further treatment is needed to prevent recurrence.[healthline.com]

Summary

In general, the medical term hernia refers to the protrusion of viscera through an orifice into the so-called hernial sac. A specific case of hernia is defined by hernial location and its content.

  • The most common form of the disease is inguinal hernia, i.e., the protrusion of abdominal viscera through the internal inguinal ring or the Hesselbach's triangle into the inguinal canal. Affected individuals are diagnosed with indirect inguinal hernia or direct inguinal hernia, respectively. Inguinal hernia accounts for up to 75% of all hernias and usually comprises the intestines [1]. A considerable share of inguinal hernias is congenital [2].
  • Femoral hernia accounts for up to 17% of all cases [1] and is defined as the protrusion of abdominal contents through the femoral ring into the femoral canal [3].
  • Less than 10% of hernias are umbilical hernias, and affected individuals suffer from the protrusion of abdominal viscera through the umbilical ring, the prior site of insertion of the umbilical cord [4].
  • Rare types of hernia include obturator hernia, epigastric hernia, hiatus hernia and other forms of diaphragmatic hernia [5], protrusion of tissues through artificial orifices [6], and traumatic hernia [5]. With regards to the contents of the hernial sac, patients may be diagnosed with Richter's hernia, Littre hernia, or cystocele, among others.

In any case, the more or less rigid boundaries of an hernial orifice may interfere with arterial blood supply and venous return from tissues contained in the hernial sac. This condition is known as strangulated hernia (SH) and may lead to blood stasis, functional impairment of affected organs and acute inflammation [7]. In the case of protruded intestines, for instance, strangulation is associated with an increased permeability of the intestinal wall and a possible breach of microorganisms. Walls of the hernial sac may eventually become gangrenous and necrotic, thus rendering SH a surgical emergency that may be associated with life-threatening sepsis.

References

Article

  1. Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011;2(1):5.
  2. Riquelme M, Aranda A, Riquelme QM. Laparoscopic pediatric inguinal hernia repair: no ligation, just resection. J Laparoendosc Adv Surg Tech A. 2010;20(1):77-80.
  3. Mifsud M, Ellul E. Meckel's diverticulum in a strangulated femoral hernia. Case report and review of literature. Ann Ital Chir. 2011;82(4):305-307.
  4. O'Donnell KA, Glick PL, Caty MG. Pediatric umbilical problems. Pediatr Clin North Am. 1998;45(4):791-799.
  5. Montresor E, Procacci C, Guarise A, et al. Strangulated traumatic hernia of the diaphragm. A report of two cases. Chir Ital. 1999;51(6):471-476.
  6. Caglia P, Tracia A, Borzi L, et al. Incisional hernia in the elderly: risk factors and clinical considerations. Int J Surg. 2014;12(Suppl 2):S164-169.
  7. Perrott CA. Inguinal hernias: room for a better understanding. Am J Emerg Med. 2004;22(1):48-50.
  8. Ozkan A, Bozkurter Cil AT, Kaya M, Etcioglu I, Okur M. Late presenting Bochdalek hernia with gastric perforation. Pediatr Emerg Care. 2015;31(1):47-49.
  9. Miyauchi T, Kuroda T, Nisioka M, et al. Clinical study of strangulation obstruction of the small bowel. J Med Invest. 2001;48(1-2):66-72.
  10. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343-403.
  11. Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc. 2013;27(1):11-18.

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Last updated: 2019-07-11 21:20