A 58-year-old man presents with abdominal swelling. He has a history of an abdominal wall hernia that even just a day ago was easily reducible.
He woke up today with significant abdominal pain and swelling that was firm and tense.
What is the diagnosis and treatment of this condition?
Diagnosis: Incarcerated Umbilical Hernia
Ahernia is the protrusion of an organ or organ fascia through a disruption in the cavity wall that normally encloses it. Common types of abdominal hernias include protrusion of omentum or bowel through an umbilical hernia, gastric organs through the diaphragm (hiatus), or bowel through either the inguinal or femoral area, but it can occur through the lumbar, sciatic, rectal, perineal, or vental tissues. (Emerg Med Clin North Am 2011;29:319.) Incisional hernias are iatrogenic, and result from the breakdown of fascial closure after surgery.
More than one million hernia operations are performed each year, of which the vast majority (greater than 75%) are inguinal hernia repairs. (Surg Clin North Am 1993;73:413.) Umbilical hernias are most common in infants, but fewer than 10 percent of children have a persistent umbilical hernia after age 1 because they self-resolve with maturity. (Pediatr Clin North Am 1998;45:773.)
Hernias are described based on the ability to place the viscous back in the cavity from which it is supposed to be contained. Reducible hernias can be repositioned either manually or spontaneously. Incarcerated hernias are not able to be reduced, but do not yet demonstrate vascular compromise as strangulated hernias do.
Incarcerated external hernias are the second most common cause of small bowel obstructions worldwide, and account for roughly five to 13 percent of all hernia repair operations (Am J Surg 2001;181:101), with only 10-15 percent of patients having necrotic bowel on gross surgical examination. (Acta Chir Scand 1989;155[11-12]:583; Am J Surg 1973;126:665.) Complications from strangulated hernias account for nearly all deaths from this condition, with an overall mortality rate ranging from six to 18 percent. (Br J Surg 1981;68:329; Br J Surg 1987;74:976; Wiad Lek 2003;56[1-2]:40; Am J Surg 2001;181:101.) Umbilical hernias account for only 15 percent of all surgical hernia repairs, but 60 percent of incarcerated umbilical hernias become strangulated. (Emerg Med Clin North Am 2011;29:319.)
Abdominal hernias are caused by factors that increase intrabdominal pressure, including lifting heavy weights, obesity, ascites, and coughing. Risk factors also include increased age, family history, and a personal history of connective tissue disease. (Emerg Med Clin North Am 2011;29:319.)
The clinical presentation of a hernia depends on which viscous is being displaced and if the displacement is causing a functional obstruction or vascular compromise to the organ itself. Patients with a hernia may present to the ED with complications, or it may be an incidental finding. Patients with symptomatic umbilical hernias may present with pain, swelling, or localized tenderness. Patients who have herniation of bowel contents may have signs of a bowel obstruction, including nausea and vomiting. Those with an incarcerated hernia may have systemic toxicity from bowel ischemia and be toxic appearing.
The physical examination should identify the fascial defect and determine if the herniated viscous is reducible or strangulated. Positioning the patient opposed of gravity (i.e., supine for evaluation of an umbilical hernia) is often necessary to get an adequate examination. Pain out of proportion to examination and persistent pain despite reduction of the viscous is concerning for an incarcerated hernia. The differential diagnosis of umbilical hernias can be extensive, and includes any etiology of abdominal pain and masses.
The evaluation of an ED patient with an umbilical hernia should determine if the patient has a strangulated or incarcerated viscous. Patients with a reducible asymptomatic hernia do not require emergency laboratory or radiologic evaluation in the ED, and can be referred for outpatient surgical evaluation. Return precautions and counseling about signs of strangulation or incarceration should be given. Patients with abdominal pain and signs of bowel obstruction should have laboratory testing including but not limited to a complete blood count, chemistry, and urinalysis. Abdominal radiographs can be performed quickly to evaluate for perforated viscous (not sensitive) or bowel obstruction, but abdominal CT imaging or ultrasound may be required to diagnose herniation of deep structures or in patients with significant adipose where the physical examination is limited.
Asymptomatic hernias that are easily reducible should be referred to a general surgeon for elective repair. Patients with a suspected strangulated or incarcerated hernia should have manual reduction attempted at the bedside. Procedural sedation, analgesia, proper positioning (supine with knees bent), firm yet gentle constant manual pressure, and possible cold packs applied to the affected area (to decrease swelling and blood flow) are typically required to achieve the ideal conditions to attempt reduction. Attempts should not be forceful. Patients who fail manual reduction warrant emergent surgical evaluation because a strangulated or incarcerated hernia is a surgical emergency. Empiric antibiotics should be initiated in patients with a suspected strangulated or incarcerated hernia, and patients should be made NPO, given parenteral hydration, and have electrolytes repleted for expectant operative management.
This patient was given antibiotics, and taken urgently for operative repair. He was diagnosed with an incarcerated ventral hernia that was repaired without incident. Post-operatively he had respiratory failure, but was eventually discharged home after prolonged hospitalization.
Dr. Wiler's column on thoracotomy in November contained an error. The incision in female patients should be made under the left breast, which should then be lifted cephalad, not caudad. EMN apologizes for the error.
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