Hernia: Difference between revisions
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{{Adult top}} [[inguinal hernia (peds)]] | |||
==Background== | ==Background== | ||
[[File:Gray1144.png|thumb|Scrotal anatomy]] | |||
===Classification=== | ===Classification=== | ||
*Reducible | *Reducible | ||
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**Impairment of blood flow | **Impairment of blood flow | ||
**Severe pain at hernia site | **Severe pain at hernia site | ||
**Signs of intestinal obstruction | **Signs of [[SBO|intestinal obstruction]] | ||
**Skin changes overlying hernia sac may be seen | **Skin changes overlying hernia sac may be seen | ||
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**Umbilical | **Umbilical | ||
***Due to conditions that increase intra-abdominal pressure (ascites, pregnancy, obesity) | ***Due to conditions that increase intra-abdominal pressure (ascites, pregnancy, obesity) | ||
***May ulcerate from ascites, see Flood Syndrome | |||
**Spigelian | **Spigelian | ||
***Also known as lateral ventral hernia | ***Also known as lateral ventral hernia | ||
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**Involves only antimesenteric border of intestine and only portion of the wall | **Involves only antimesenteric border of intestine and only portion of the wall | ||
**Often presents with out vomiting or intestinal obstruction | **Often presents with out vomiting or intestinal obstruction | ||
***As a result, more likely to diagnose once wall has begun to become ischemic | ***As a result, more likely to diagnose once wall has begun to become ischemic | ||
==Clinical Features== | ==Clinical Features== | ||
*Hernia (usually) palpable on exam | |||
**If incarcerated, nonreducible | |||
**If strangulated, nonreducible and may have overlying skin changes | |||
*+/- [[abdominal pain|abdominal]]/groin/[[testicular Pain]] | |||
*+/- signs/symptoms of [[SBO]], [[peritonitis]] if strangulated | |||
[[File:Hernia Locations.jpeg|thumb]] | [[File:Hernia Locations.jpeg|thumb]] | ||
[[File:Inguinal hernia.JPG|thumb]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Template:Testicular DDX}} | {{Template:Testicular DDX}} | ||
== | ==Evaluation== | ||
===Work-Up=== | ===Work-Up=== | ||
*Labs | *Labs | ||
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**Consider CBC, chemistry, lactate if concern for strangulation | **Consider CBC, chemistry, lactate if concern for strangulation | ||
*Imaging | *Imaging | ||
** | **CT, if concern for obstruction/strangulation | ||
**Ultrasound (only indicated to exclude other diagnoses | **Ultrasound (only indicated to exclude other diagnoses) | ||
==Management== | ==Management== | ||
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***Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis | ***Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis | ||
**NPO (in case reduction unsuccessful) | **NPO (in case reduction unsuccessful) | ||
**IV | **IV [[opioid]] analgesia | ||
**Supine and mild | **Supine and mild Trendelenburg positioning | ||
**Apply cold packs to hernia site to reduce swelling | **Apply cold packs to hernia site to reduce swelling | ||
**Apply firm, steady pressure to distal part of hernia | **Apply firm, steady pressure to distal part of hernia | ||
**If successful observe patient in ED period of time for serial | **If successful observe patient in ED period of time for serial abdominal exams | ||
**If unsuccessful after 1 or 2 attempts consult surgery | **If unsuccessful after 1 or 2 attempts consult surgery | ||
*Antibiotics (e.g. [[Cefoxitin]]) for | *Antibiotics (e.g. [[Cefoxitin]]) for | ||
** | **[[Bowel obstruction]] | ||
**Peritonitis | **[[Peritonitis]] | ||
==Disposition== | ==Disposition== |
Revision as of 21:43, 25 July 2021
This page is for adult patients. For pediatric patients, see: inguinal hernia (peds)
Background
Classification
- Reducible
- Hernia sac soft, easy to replace back through the hernia defect
- Incarcerated
- Hernia sac firm, often painful, nonreducible
- Strangulation
- Impairment of blood flow
- Severe pain at hernia site
- Signs of intestinal obstruction
- Skin changes overlying hernia sac may be seen
Types
- Inguinal (75%)
- Most common type of hernia in both men and women
- Presents as groin mass
- Indirect (50%)
- Hernia passes from inguinal ring into scrotum (due to patent processus vaginalis)
- Direct (25%)
- Hernia passes directly through transversalis fascia in Hesselbach triangle
- Ventral
- Due to defect in anterior abdominal wall (spontaneous or acquired)
- Incisional
- Due to excess wall tension or inadequate wound healing / surgical wound infection
- Umbilical
- Due to conditions that increase intra-abdominal pressure (ascites, pregnancy, obesity)
- May ulcerate from ascites, see Flood Syndrome
- Spigelian
- Also known as lateral ventral hernia
- Nearly always acquired conditions
- Difficult to diagnose
- Classic presentation is abdominal pain associated with anterior lateral abdominal wall mass
- Physical exam is unreliable; imaging (US or CT) is often required
- Femoral
- 10:1 female:male ratio
- Hernia sac protrudes through femoral canal
- Mass is typically below the inguinal ring
- Particularly prone to complications
- Obsturator
- Bowel herniation through obturator canal
- Nearly always presents as partial or complete bowel obstruction
- High complication rate
- Richter
- Involves only antimesenteric border of intestine and only portion of the wall
- Often presents with out vomiting or intestinal obstruction
- As a result, more likely to diagnose once wall has begun to become ischemic
Clinical Features
- Hernia (usually) palpable on exam
- If incarcerated, nonreducible
- If strangulated, nonreducible and may have overlying skin changes
- +/- abdominal/groin/testicular Pain
- +/- signs/symptoms of SBO, peritonitis if strangulated
Differential Diagnosis
Testicular Diagnoses
- Scrotal cellulitis
- Epididymitis
- Fournier gangrene
- Hematocele
- Hydrocele
- Indirect inguinal hernia
- Inguinal lymph node (Lymphadenitis)
- Orchitis
- Scrotal abscess
- Spermatocele
- Tinea cruris
- Testicular rupture
- Testicular torsion
- Testicular trauma
- Testicular tumor
- Torsion of testicular appendage
- Varicocele
- Pyocele
- Testicular malignancy
- Scrotal wall hematoma
Evaluation
Work-Up
- Labs
- Not routinely necessary
- Consider CBC, chemistry, lactate if concern for strangulation
- Imaging
- CT, if concern for obstruction/strangulation
- Ultrasound (only indicated to exclude other diagnoses)
Management
- Reduction for incarcerated hernia
- If there is any concern for strangulation, do not attempt hernia reduction
- Reintroduction of ischemic bowel back into peritoneal cavity can result in sepsis
- NPO (in case reduction unsuccessful)
- IV opioid analgesia
- Supine and mild Trendelenburg positioning
- Apply cold packs to hernia site to reduce swelling
- Apply firm, steady pressure to distal part of hernia
- If successful observe patient in ED period of time for serial abdominal exams
- If unsuccessful after 1 or 2 attempts consult surgery
- If there is any concern for strangulation, do not attempt hernia reduction
- Antibiotics (e.g. Cefoxitin) for
Disposition
- Discharge with surgery referral:
- Easily reducible hernia
- Spigelian, femoral, obturator, Richter hernias (all have high rates of incarceration)