What is the appropriate management for a boy with sudden groin pain, a non‑reducible groin mass, fever and markedly elevated white‑blood‑cell count after playing football?

Management of Suspected Strangulated Inguinal Hernia in a Pediatric Patient

This boy requires immediate surgical exploration for a strangulated inguinal hernia. The combination of sudden groin pain during physical activity, a non-reducible groin mass without cough impulse, fever, and markedly elevated WBC count (130,000/µL) indicates incarcerated hernia with likely strangulation and possible bowel necrosis 1, 2.

Critical Clinical Features Indicating Surgical Emergency

The clinical presentation strongly suggests strangulation rather than simple incarceration:

• Non-reducible mass without cough impulse indicates the hernia contents are trapped and the communication with the peritoneal cavity is compromised 3, 4
• Fever with extreme leukocytosis (WBC 130,000/µL) signals systemic infection or tissue necrosis—this degree of leukocytosis far exceeds typical bacterial infection (which usually shows WBC <20,000/µL) and suggests bowel ischemia with bacterial translocation or frank necrosis 1, 2
• Acute onset during athletic activity is the classic mechanism for hernia incarceration in active children 3

Why Other Options Are Inappropriate

Aspiration (Option A) is contraindicated because:

• A non-reducible hernia with systemic signs is not a hematoma—hematomas do not cause fever or extreme leukocytosis 1
• Needle aspiration of incarcerated bowel risks perforation and peritonitis 4

Observation with analgesics (Option B) is dangerous because:

• Strangulated hernias require surgery within hours to prevent bowel necrosis and perforation 4
• The extreme WBC elevation (130,000/µL) indicates advanced tissue compromise that will not resolve spontaneously 1, 2
• Delayed intervention increases mortality risk from sepsis and bowel gangrene 1

Manual reduction (Option D) is contraindicated because:

• Forceful reduction of a strangulated hernia can cause "reduction en masse" where necrotic bowel is pushed back into the abdomen, converting an external emergency into an internal one 5
• The presence of fever and extreme leukocytosis suggests the bowel may already be necrotic—reducing necrotic tissue intraperitoneally causes peritonitis and sepsis 1, 5
• Manual reduction can perforate compromised bowel 4

Recommended Immediate Management Algorithm

Step 1: Resuscitation (initiate immediately)

• Establish IV access and begin aggressive fluid resuscitation (2.5-3 liters/m²/day) 1
• Obtain blood cultures before antibiotics 1
• Start broad-spectrum IV antibiotics covering mixed aerobic-anaerobic flora (vancomycin or linezolid PLUS piperacillin-tazobactam or a carbapenem) 1
• NPO status with nasogastric decompression if signs of bowel obstruction 4

Step 2: Urgent surgical consultation (within 1 hour)

• Prompt surgical consultation is mandatory for aggressive infections with signs of systemic toxicity 1
• The combination of non-reducible hernia, fever, and WBC 130,000/µL constitutes a surgical emergency requiring exploration within 2-4 hours 1, 4

Step 3: Surgical exploration

• Open surgical approach is recommended given the high likelihood of bowel compromise requiring assessment of viability 1, 4
• Intraoperative assessment for bowel necrosis, with resection if non-viable 1
• Mesh repair should be deferred if bowel resection is required or if there is gross contamination 4

Critical Pitfalls to Avoid

• Do not delay surgery for imaging—the clinical diagnosis is clear and imaging will only postpone life-saving intervention 1, 4
• Do not attempt manual reduction in the presence of systemic signs (fever, extreme leukocytosis)—this risks reduction en masse with necrotic bowel 5
• Do not underestimate the severity based on the patient's age—pediatric patients can deteriorate rapidly from strangulated hernias 1
• Do not use narrow-spectrum antibiotics—strangulated bowel with bacterial translocation requires coverage for polymicrobial infection including anaerobes 1