From the Guidelines
The best approach to assess for a hernia involves a comprehensive physical examination combined with appropriate imaging when necessary, prioritizing early detection of complications such as intestinal strangulation, which can significantly impact morbidity, mortality, and quality of life. Begin with a thorough history to identify risk factors and symptoms such as pain, bulging, or discomfort that worsens with straining 1. The physical examination should be performed with the patient both standing and lying down, asking them to cough or perform a Valsalva maneuver to increase intra-abdominal pressure. Palpate the suspected hernia site, noting any bulges, tenderness, or reducibility. For inguinal hernias, examine the inguinal canal by invaginating the scrotum with your finger while the patient coughs. For femoral hernias, palpate below the inguinal ligament.
When physical examination findings are equivocal, imaging studies can be valuable, with ultrasound being the first-line option due to its accessibility, lack of radiation, and dynamic assessment capabilities 1. CT scans provide better anatomical detail for complex or recurrent hernias. MRI may be useful in specific cases, particularly for sports hernias. Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, CPK, and D-dimer levels are predictive of bowel strangulation, guiding the need for immediate surgical intervention 1.
Key points to consider in the assessment include:
- Early detection of intestinal strangulation is crucial to prevent high morbidity and mortality rates 1.
- The use of diagnostic laparoscopy may be beneficial in assessing bowel viability after spontaneous reduction of strangulated groin hernias 1.
- A comprehensive approach combining clinical assessment with appropriate imaging ensures accurate diagnosis and guides treatment decisions, ultimately impacting patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Assessment Approach for Hernia
To assess for a hernia, the following steps can be taken:
- A thorough history and physical examination are usually sufficient to make the diagnosis 2, 3
- Symptomatic patients often have groin pain, which can sometimes be severe, and a heavy or dragging sensation may worsen toward the end of the day and after prolonged activity 2
- Examination involves feeling for a bulge or impulse while the patient coughs or strains 2
- An abdominal bulge may disappear when the patient is in the prone position 2
Diagnostic Tools
- Imaging is rarely warranted, but ultrasonography or magnetic resonance imaging can help diagnose a hernia in an athlete without a palpable impulse or bulge on physical examination 2
- Ultrasonography may also be indicated with a recurrent hernia or suspected hydrocele, when the diagnosis is uncertain, or if there are surgical complications 2
- A hand-held Doppler device can be used in addition to physical examination to differentiate types of inguinal hernia 4
Special Considerations
- An abdominal wall hernia is characterized by an increase in swelling on standing physical examination and Valsalva maneuver, which is often reducible, and a hernia defect is palpable 3
- If no interruption of the abdominal wall is palpable and there is hypoesthesia, there may be an abdominal wall paresis because of thoracic paramedian hernia nuclei pulposi (HNP) 3
- Paraesophageal hernia (PEH) patients are usually symptomatic with GERD or obstructive symptoms, such as dysphagia, and a thorough evaluation includes a complete history and physical examination, chest radiograph, UGI series, esophagogastroscopy, and manometry 5