Strangulated Hernia

A strangulated hernia occurs when the blood supply to the herniated tissue has been cut off. This strangulated tissue can release toxins and infection into the bloodstream, which could lead to sepsis or death. Strangulated hernias are medical emergencies.

A hernia is a weak spot or other abnormal opening in a body wall that permits part of the organ to bulge through.

• It may develop in various parts of the body, most commonly in the region of the abdomen (abdominal hernia), and may be either acquired or congenital.
• When these muscles become too weak, organ tissue might push through the muscle, creating a noticeable bulge in the skin. Hernias may also be tender to the touch and can cause discomfort in the upper or lower abdomen or groin, especially when lifting, coughing, or bending over.
• The abdominal wall has some natural weak spots - where the blood vessels serving the scrotum and leg pierce it, in the umbilicus (navel) region and the diaphragm.
• This defect in the peritoneum allows organs and tissues to push through, or herniate, producing a bulge. The lump may disappear when the person lies down, and sometimes it can be pushed back in. Coughing may make it reappear.
  • Except in the case of umbilical hernias — which are present at birth and usually disappear by age 3 or 4 — hernias don’t go away on their own.

Any hernia can become strangulated. A strangulated hernia is a hernia that is cutting off the blood supply to the intestines and tissues in the abdomen.

Symptoms of a strangulated hernia include pain near a hernia that gets worse very quickly and may be associated with other symptoms. Anyone who suspects they have a strangulated hernia should seek emergency medical care.

Types of hernias:

• Groin:
  • a femoral hernia creates a bulge just below the groin or inner upper area of the thigh.
    • This is more common in women.
  • An inguinal hernia, a bulge on either side of the pubic bone. It is a bulge in the groin that may reach the scrotum.
    • Inguinal hernia is the most common form of hernia in men, accounting for around 94% of all cases.
• Upper part of the stomach (epigastric): a hiatal or hiatus hernia is caused by the upper part of the stomach pushing out of the abdominal cavity and into the chest cavity through an opening in the diaphragm.
  • Men are three times more likely to have epigastric hernia than women.
• Belly button (umbilicus): a bulge caused by the intestines protruding through weaker abdominal muscles in this area produces an umbilical or periumbilical hernia,
• Surgical scar: past abdominal surgery, that hasn’t entirely or correctly healed, can lead to an incisional hernia through the scar.
• Incarcerated hernias: occur when the herniated tissue gets trapped and cannot move back into place, but the blood supply to the tissues has not been cut off. However they can easily lead to strangulated hernias. It is not a medical emergency, but should still be treated quickly to prevent them becoming strangulated.
• See this site for other types of hernias: The Free Medical Dictionary (Cite: Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders) - Strangulated hernia

Causes

• With the exception of an incisional hernia (a complication of abdominal surgery), in most cases, there is no obvious reason for a hernia to occur.
  • The risk of hernia increases with age and occurs more commonly in men than in women.
• A hernia can be congenital (present at birth) or develop in children who have a weakness in their abdominal wall.
• Some activities and medical problems can increase pressure on the abdominal wall leading to a hernia. Some of these include:
  • straining on the toilet (due to long-term constipation, for example)
  • persistent cough
  • cystic fibrosis
  • enlarged prostate
  • straining to urinate
  • being overweight or obese
  • abdominal fluid
  • lifting heavy items
  • peritoneal dialysis
  • poor nutrition
  • smoking
  • physical exertion
  • undescended testicles

Risks for hernias based on type

• Incisional hernia risk factors:
  • Because an incisional hernia is the result of surgery, the clearest risk factor is a recent surgical procedure on the abdomen.
  • People are most susceptible 3-6 months after the procedure, especially if:
    • they are involved in strenuous activity
    • have gained additional weight
    • become pregnant
  • These factors all put extra stress on tissue as it heals.
• Inguinal hernia risk factors
  • older adults
  • people with close relatives who have had inguinal hernias
  • people who have had inguinal hernias previously
  • males
  • smokers, as chemicals in tobacco weaken tissues, making a hernia more likely
  • people with chronic constipation
  • premature birth and low birth weight
  • pregnancy
• Umbilical hernia risk factors
  • Umbilical hernias are most common in babies with a low birth weight and premature babies.
  • In adults, the risk factors include:
    • being overweight
    • having multiple pregnancies
    • being female
• Hiatal hernia risk factors
  • The risk of hiatal hernia is higher in people who:
    • are aged 50 years or over
    • have obesity

Symptoms of strangulated hernias

• One common indication of a strangulated hernia is an easily visible bulge in the areas of the abdomen or pelvis. This bulge grows quickly or harden.
• Other symptoms that may accompany the bulge include:
  • sudden pain that can quickly become excruciating
  • nausea
  • vomiting
  • fever
  • color changes (darkening or reddening) in the skin over or near the hernia
  • severe constipation or an inability to have a bowel movement
  • inability to pass gas
  • inflammation or tenderness around the hernia
  • burning feeling around the hernia
  • bloody stools
  • rapid heart rate
  • general fatigue

What complications may occur without treatment?

• If left untreated, the strangulated fold of tissue or small intestine will be cut off from its blood supply. It can become gangrenous within hours. As the tissue dies off, it releases dangerous toxins into the bloodstream. That can lead to sepsis and eventual death.
• At best a strangulated hernia can be extremely painful and is a surgical emergency. That means they require urgent professional attention.
  • Also, patients tend to do less well after emergency surgery than they do following planned procedures. A large study in Sweden concluded:
    • “Mortality risk following elective hernia repair is low, even at high age.
    • An emergency operation for groin hernia carries a substantial mortality risk.*”
    • The risk of mortality is 7 times higher when a hernia operation is carried out as an emergency and 20 times higher if a bowel resection was involved!
  • Clearly, the evidence shows it is vastly preferable to prevent strangulation and avoid emergency surgery in the first place. In other words never let it get that bad.

Hernia Statistics

• The lifetime risk of a groin hernia is 27% for men and 3% for women.
• Inguinal, femoral and abdominal hernias resulted in 32,000 deaths worldwide in 2013, or 0.5 per 100,000.
• The frequency of surgical correction ranges from 10 per 100,000 (U.K.) to 28 per 100,000 (U.S.).
• Groin hernias occur in approximately 2% of the adult population and 4% of infants. Their relative frequencies are:
  • Inguinal 80%
  • Incisional 10%
  • Femoral 5%
  • Umbilical 4%
  • Epigastric <1%
  • Other: <1%

What's the outlook?

• Elective hernia repair has a high success rate, but the hernia may recur in between one to 20 per cent of cases. Recurrence is more likely with traditional surgery, but also depends upon the type of hernia and any complicating health factor. Mesh repair of a simple case of abdominal hernia is almost certain to last for life. Once a hernia has recurred it does, however, become progressively harder to repair on subsequent occasions.
• The do-it-yourself hernia operation. by John Parsons, Esq. (image 1)

Resources & Additional Reading

• The Free Medical Dictionary - Strangulated hernia
• MedicalNewsToday - What is a strangulated hernia? By Jon Johnson. Last reviewed 11 Feb 2018
• MedicalNewsToday - Types and treatments for hernias. By: Markus MacGill. Last updated 13 Nov 2017
• Mayo Clinic - Inguinal hernia Overview
• HealthLine - What is a Strangulated Hernia? By Jamie Ludwig; Medically reviewed by Alana Biggers, MD on 26 Jul 2017
• The British Hernia Centre - Strangulated Hernia
• Healthline - Umbilical Hernia. by Shannon Johnson & Jacquelyn Cafasso. Reviewed by Stacy Sampson, DO on 15 Dec 2017
• Mayo Clinic - Umbilical Hernia, Overview
• Mayo Clinic - Inguinal hernia, Overview
• Men’s Health Forum - Hernia FAQS
• Disabled World. Revised/updated: 3/11/2015
• Strangulated Hernia. by Tak Berkategori, 19 Aug 2017 (image 2)

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