What are the key history questions to ask when evaluating a patient for an abdominal hernia?

Key History Questions for Abdominal Hernia Evaluation

When evaluating a patient for an abdominal hernia, a focused history targeting specific symptoms, risk factors, and complications is essential for accurate diagnosis and timely intervention.

Cardinal Symptoms to Assess

• Pain characteristics:

  • Onset (sudden vs. gradual)
  • Location and radiation
  • Quality (colicky, sharp, dull)
  • Relationship to physical activities (lifting, straining, coughing)
  • Relationship between pain and bowel movements 1

• Bowel function changes:

  • Last normal bowel movement
  • Changes in bowel habits (constipation, diarrhea)
  • Passage of flatus (absence may indicate obstruction)
  • Nausea and vomiting (especially feculent vomiting suggesting distal obstruction) 1

Critical Warning Signs of Complications

• Strangulation indicators:

  • Continuous, severe, non-relieving pain
  • Fever and systemic symptoms
  • Inability to reduce a previously reducible hernia 1

• Obstruction indicators:

  • Progressive abdominal distension
  • Persistent vomiting
  • Complete cessation of flatus/bowel movements 1

Essential Risk Factor Assessment

• Previous surgeries:

  • Type and timing of previous abdominal operations (85% sensitivity for adhesive small bowel obstruction) 1
  • Previous hernia repairs and techniques used (mesh vs. non-mesh)

• Medical history:

  • Chronic cough, COPD, or smoking
  • Chronic constipation or straining
  • Pregnancy history and number of deliveries
  • Obesity and recent weight changes
  • Connective tissue disorders 1

Medication and Lifestyle Factors

• Current medications:

  • Medications affecting peristalsis (may mimic obstruction)
  • Anticoagulants (relevant for surgical planning)
  • Steroids or immunosuppressants (affect wound healing)

• Occupational and lifestyle factors:

  • Heavy lifting requirements
  • Exercise habits
  • Impact on quality of life and daily activities 2

Specific Questions for Recurrent Hernias

• Timeline of previous hernia diagnosis and repair
• Type of repair performed (open vs. laparoscopic)
• Type of mesh used (if applicable)
• Post-operative complications after previous repairs
• Duration between repair and recurrence 1

Algorithm for Evaluating Hernia Urgency

1. Emergent intervention needed if:

   • Persistent severe pain AND
   • Signs of systemic inflammatory response (fever, tachycardia, tachypnea) OR
   • Irreducible hernia with obstruction symptoms 1

2. Urgent evaluation needed if:

   • New onset irreducible hernia without severe pain OR
   • Intermittent obstructive symptoms with reducible hernia

3. Routine evaluation appropriate if:

   • Longstanding reducible hernia
   • Minimal symptoms
   • No signs of complications

Common Pitfalls to Avoid

• Failure to recognize atypical presentations:

  • Internal hernias may present with vague symptoms
  • Diaphragmatic hernias may present with both respiratory and abdominal symptoms 1

• Overlooking small hernias:

  • Small femoral hernias are easily missed but have high strangulation risk
  • Obturator hernias often present with vague symptoms or Howship-Romberg sign

• Missing complications in pregnant patients:

  • Pregnancy can increase risk of internal herniation and intestinal obstruction, especially after bariatric surgery 1

Remember that early diagnosis of strangulated obstruction can be difficult, and delayed diagnosis leads to septic complications. When intestinal strangulation is suspected, immediate surgical intervention is warranted as the benefits outweigh the risks 1.