UOTW #40

46 yo healthy male presents with slowly worsening left groin pain. The patient works in manual labor. On exam he is in mild distress and points to an area just lateral to his pubic symphysis, stating that he has an aching pain in that region that is worse as the day progresses. On physical exam, the vitals are normal except for mild tachycardia. No obvious bulge, swelling or skin changes seen over the area, and palpation does not elicit any obvious findings of a hernia, however suspicion still remains high. An ultrasound is brought into the room revealing the following images:



Diagnosis: Incarcerated inguinal hernia

Bedside ultrasound showed a small loop of small bowel incarcerated within a defect in the fascia. Power Doppler failed to show any signs of blood flow around the hernia, increasing concern for strangulation. Emergent surgical consultation was performed and the patient was then taken to the operating room.

  • The overall lifetime risk of the development of a hernia in the groin has been estimated to be 27% in men and 3% in women,1 and more than 600,000 surgical repairs for inguinal hernias are performed every year in the United States.2 Conditions associated with increased risk of hernia include COPD and smoking, lower BMI, collagen vascular disease, aortic aneurysm, patent processus vaginalis, history of open appendectomy, and peritoneal dialysis.1 Of note, weight-lifting has not been shown to increase incidence of hernia.1
  • Approximately 75% of all hernias occur in the inguinal region, with the most common location being the right groin.1
  • Physical exam is the initial test of choice in the diagnosis of an inguinal hernia.2 The specificity of physical exam has been reported to be 96.3%. However, that same study found physical exam to have a sensitivity of 74.5%.3
  • When the decision is made to pursue further imaging, ultrasound is the next recommended choice for evaluation due to its ability to be used at the bedside, high sensitivity, and lack of ionizing radiation. However, it has been known to depend on the operator performing the examination.1 A meta-analysis that included 9 articles found ultrasound to have a pooled sensitivity of 96.6% and a pooled specificity of 84.8%.4
  • The high frequency has been described as the probe of choice for this examination.5
  1. Fitzgibbons RJ, Forse RA. Clinical practice. Groin hernias in adults. N Engl J Med. 2015;372:(8)756-63. [pubmed]
  2. LeBlanc KE, LeBlanc LL, LeBlanc KA. Inguinal hernias: diagnosis and management. Am Fam Physician. 2013;87:(12)844-8. [pubmed]
  3. van den Berg JC, de Valois JC, Go PM, Rosenbusch G. Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34:(12)739-43. [pubmed]
  4. Robinson A, Light D, Nice C. Meta-analysis of sonography in the diagnosis of inguinal hernias. J Ultrasound Med. 2013;32:(2)339-46. [pubmed]
  5. Jamadar DA, Jacobson JA, Morag Y, et al. Characteristic locations of inguinal region and anterior abdominal wall hernias: sonographic appearances and identification of clinical pitfalls. AJR Am J Roentgenol. 2007;188:(5)1356-64. [pubmed]