What is the recommended workup for a suspected hernia?

Hernia Workup

For suspected hernias, begin with physical examination for inguinal hernias in men, but use ultrasonography as the first-line imaging for women, obese patients, or when diagnosis is uncertain; for diaphragmatic hernias, start with chest X-ray followed by CT scan with contrast if suspicion remains high. 1

Initial Clinical Assessment

Inguinal Hernias

• Physical examination alone confirms diagnosis in the vast majority of male patients with appropriate signs and symptoms. 2
• Ultrasonography is often needed in women to establish the diagnosis, as groin hernias are more difficult to diagnose clinically in female patients. 3
• Look for specific risk factors including: family history, previous contralateral hernia, male gender, advanced age, abnormal collagen metabolism, history of prostatectomy, and low body mass index. 2

When Physical Examination is Insufficient

• Ultrasonography is the first imaging modality when physical examination is equivocal, in obese patients, or when evaluating for recurrent hernia or surgical complications. 3, 2
• MRI has higher sensitivity and specificity than ultrasonography and should be used for diagnosing occult hernias if clinical suspicion remains high despite negative ultrasound findings. 3
• Herniography (contrast injection into hernial sac) may be used in highly selected patients when other modalities are inconclusive. 3

Diaphragmatic Hernia Workup

Non-Pregnant Patients

• Chest X-ray (both anteroposterior and lateral views) is the first diagnostic study for patients presenting with respiratory symptoms. 1
• Look for these specific findings on chest X-ray: abnormal bowel gas pattern, air-fluid level, abnormal lucency, soft tissue opacity with mediastinal deviation, or hemidiaphragm elevation. 1
• If clinical suspicion remains high despite normal chest X-ray, proceed to CT scan with contrast enhancement of chest and abdomen. 1
• Be aware that normal chest radiographs occur in 11-62% of diaphragmatic injuries or uncomplicated diaphragmatic hernias, so maintain high clinical suspicion. 1

CT Scan Findings

• CT scan is the gold standard with sensitivity of 14-82% and specificity of 87%. 1
• Look for these specific CT findings: diaphragmatic discontinuity, "dangling diaphragm" sign, "dependent viscera" sign, and "collar sign". 1
• Multislice CT with coronal and sagittal reformatted images is the most effective imaging technique for diaphragmatic hernias. 4
• CT shows herniated abdominal organs together with complications such as intestinal strangulation, hemothorax, and rib fractures. 4

Special Populations

• For pregnant patients, begin with ultrasonography as the first diagnostic study, followed by MRI if needed to avoid radiation exposure. 1
• In stable trauma patients, CT scan with contrast enhancement is strongly recommended. 1
• For stable trauma patients with lower chest penetrating wounds, diagnostic laparoscopy is recommended. 1
• Endoscopy is not recommended for traumatic hernias. 1

Hiatal Hernia Workup

• For epigastric pain with suspected hiatal hernia, fluoroscopy studies are the initial imaging of choice, including fluoroscopy biphasic esophagram, fluoroscopy single-contrast esophagram, and fluoroscopy upper GI series. 1
• Double-contrast upper GI series is particularly useful as it provides information on esophageal length, strictures, and reflux in addition to confirming the hernia. 1

Hernia Classification

• Use the EHS classification system to stratify inguinal hernia patients for tailored treatment, research, and audit purposes. 2
• Document hernia size, location (medial vs lateral), and whether primary or recurrent. 2

Additional Imaging Considerations

• CT imaging is valuable when patients are obese or have had previous surgery, as it can distinguish hernias from abdominal wall masses such as tumors, hematomas, abscesses, undescended testes, and aneurysms. 5
• Ultrasound is particularly useful in traumatic diaphragmatic hernia cases as it shows diaphragmatic continuity, herniated organs, and associated abdominal organ pathologies. 4
• MRI may be performed in selected patients with late-presenting diaphragmatic hernias or when diagnosis remains in doubt after other imaging, given its high sensitivity for soft tissue. 4

Common Pitfalls

• Intermittent herniation may appear normal on chest X-ray but can be detected on CT scan. 1
• CT scan may miss small tears from penetrating injuries like stab wounds when no hernia has yet occurred. 1
• Delayed presentation of diaphragmatic hernia is common and can be asymptomatic for decades before becoming symptomatic. 1
• Consider placing a nasogastric tube to help identify herniated stomach on imaging when diaphragmatic hernia is suspected. 1