1. Ang, Jessy Aningalan, Arvin
Case 2
Ang, Jessy
Aningalan, Arvin

2. Case 2
A 25-year old male waiter comes to the Emergency Room because of a R inguinal mass. Since two years ago, the mass would appear when lifting heavy objects, coughing, or sneezing and spontaneously disappear upon lying down aided by gentle manual manipulation.

3. Diagnosis Direct Inguinal Hernia Indirect Inguinal Hernia
Enters through a weak point in the fascia of the abdominal wall (Hesselbach triangle).
Sac protrudes directly outward & forward
Congenital
Patent processus vaginalis
Passes through the internal inguinal ring
Located lateral to the inferior epigastric vessels
More prone to incarceration
Most common hernia
Sac passes obliquely or indirectly toward & ultimately into the scrotum

4. Diagnosis Based on the description of the case:
Direct Inguinal Hernia (Right inguinal mass, did not go through the scrotum)
Reducible (“Spontaneously disappear upon lying down aided by gentle manual manipulation.”)
Caused by an Increased Abdominal Pressure (lifting heavy objects, coughing, or sneezing)

5. Six hours prior to admission, upon lifting a case of beer, the mass protrudes to its largest size and cannot be pushed back anymore even with manipulation. The mass this time becomes painful and tender rendering him unable to walk.

6. What would you recommend for him?
With the case of the patient, we must first differentiate if it is strangulated or just incarcerated.

7. Incarcerated Strangulated
It may be an occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it.
Some may be chronic (occur over a long term) without pain.
It can lead to strangulation.
Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting.
It's an irreducible hernia in which the entrapped intestine has its blood supply cut off.
Pain is always present, followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting).
The affected person may appear ill with or without fever.
It's a surgical emergency.

8. Based on the description of the case:
Direct Inguinal Hernia (Right inguinal mass, did not go through the scrotum)
Irreducible/Incarcerated (“cannot be pushed back anymore .”)
Caused by an Increased Abdominal Pressure (“upon lifting a case of beer”)

9. He is given a muscle relaxant – sedative parenterally after which he falls asleep. One hour later, you come back and re-evaluate him. The mass has now disappeared and he has become completely asymptomatic. He now wants to go home.

10. What Would You Advise the Patient?
The patient maybe discharged, but must be advised to have corrective surgery.
a hernia that was irreducible and is reduced has a dramatically increased risk of doing so again.
Advise patient also of risks of recurrence:
coughing, sneezing, straining during defecation or urination
overexertion at work

11. Do you agree with how he was managed at the Emergency Room?
Management for an irreducible hernia includes:
An attempt to reduce (push back) the hernia will generally be made, often with medicine for pain and muscle relaxation.
If unsuccessful, emergency surgery is needed. 
If successful, however, treatment depends on the length of the time that the hernia was irreducible.
If the intestinal contents of the hernia had the blood supply cut off, the development of dead (gangrenous) bowel is possible in as little as six hours.
In cases where the hernia has been strangulated for an extended time, surgery is performed to check whether the intestinal tissue has died and to repair the hernia.
In cases where the length of time that the hernia was irreducible was short and gangrenous bowel is not suspected, you may be discharged.

12. So yes, the management was correct.
The patient showed no signs of intestinal necrosis, so no surgery was needed to explore the hernia.