A structure that protrudes through another ending up in the wrong place can be classed as a hernia.
Describing hernias can be tricky so learn these terms:- Irreducible: a hernia involving bowel if it cannot be pushed back into place. Incarcerated: a hernia where the contents of the hernial sac are stuck to one another by adhesions. Obstructed: a hernia where the contents of the bowel can no longer move through and are stuck within the hernial sac. Strangulated: a hernia where ischaemia has occured. This is a surgical emergency as the ischaemic bowel is at a greater risk of dying and subsequently perforating.
Classification of Hernias
Diagnosis and Differential
The diagnosis is clinical however some investigations can be performed to understand the level of complication. When examining the patient, they must be stood up, as some hernias reduce when lying down. Increasing intra-abdominal pressure through asking the patient to cough or perform the valsalva manouvre can uncover hernias. Examining the hernial orifices should focus on the abdomen, surgical incision sites, inguinal area and femoral triangle.
Evaluating for provocating factors such as prostatism, chronic cough, severe constipation, ascites and rectal cancer will aid in your management plan.
Differential Diagnosis: Not all inguinal masses are hernias.
- Local adenopathy may be a result of local infection or malignancy
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Signs and Symptoms
- Most commonly, patients complain of a visible bulge that may causes a vague discomfort.
- Hernias may be asymptomatic.
- Pain is not a feature of all hernias.
- Most hernias, even large ones, will allow reduction with gentle pressure.
- Incarcerated hernias: cannot be reduced but don't usually have any other symptoms such as pain, discomfort or erythema of overlying skin.
- Strangulated hernias: give a history of steady and gradually increasing pain with the additional symptoms of nausea and vomiting. A strangulated hernia is ischaemic which can lead to perforation and gangrene. The hernia itself may be tender to touch and the overlying skin erythematous. Signs of peritonitic abdomen may also be present i.e guarding, rebound tenderness and pain. The warning signs of this hernia should not be missed! Act quickly!
- Obstructed hernias: prevent the contents of the bowel from moving along its natural path. If the obstructed hernia is irreducible and faeces builds up behind the hernia then perforation is a possible complication.
- IMPORTANT: When trying to reduce a hernia, correct technique is of the upmost importance. Reducing a strangulated hernia may give the initial impression of a successful reduction however the still strangulated hernial sac has been pushed back into the abdomen. This is known as reduction en masse.
For a comprehensive guide to examination see the Fastbleep 'Examination of hernial orifices' article.
- Longmore, Murray. Wilkinson, Ian. Turmezie, Tom. Cheung, Chee Kay. Oxford Handbook of Clinical Medicine, Surgery, Hernias, 7th ed, pp. 630-631
- eMedicine. Abdominal Hernias. Available from: http://emedicine.medscape.com/article/189563-overview [Accessed 08 March 2011]
- Merck Manuals: Professional Edition, Gastrointestinal Disorders, Acute Abdomen and Surgical Gastroenterology, Hernias of the Abdominal wall. Available from: http://www.merckmanuals.com/professional/sec02/ch011/ch011f.html?qt=hernias&alt=sh [Accessed 08 March 2011]