Pediatric emergency medicine trisk 3760 3760

usually involves the ovary rather than the intestine. Often, the patient or family
has no previous knowledge of the presence of a congenital hernia. Incarceration
does not necessarily mean that the nonreducible portion of intestine is
compromised or gangrenous. However, strangulation can occur within 24 hours
of a nonreduced incarcerated hernia because of progressive edema of the bowel
caused by venous and lymphatic obstruction. This obstruction then leads to
occlusion of the arterial supply with resulting necrosis of the bowel and perhaps
perforation.
Clinical Considerations
Triage Considerations. Children presenting with an inguinal mass should be
assessed for bowel obstruction or strangulation. If the child is vomiting, has
significant pain, or the hernia is discolored, the patient should be seen
immediately to determine whether emergent surgical consultation is required even
prior to imaging or attempts at reduction.
Initial Assessment. The clinical presentation of a child with an incarcerated
hernia is irritability due to pain, vomiting, and occasionally abdominal distension.
A firm, discrete mass can be palpated at the internal ring that may or may not
extend into the scrotum. Occasionally, the testicle may appear dark blue because
of venous congestion, and in a prolonged incarceration, the testicle may be
infarcted. Intestinal obstruction may develop quickly, and an abdominal
radiograph exhibits signs of small bowel obstruction and possibly gas-filled loops
of intestine in the scrotum. Lack of air in the inguinal region cannot be used to
exclude a hernia because the intestine, especially when incarcerated, is often fluid
filled.
It is often difficult to differentiate a tense hydrocele in the scrotum from an
incarcerated hernia. If the child has had a hydrocele, a sudden increase in fluid in
the tunica vaginalis may produce discomfort and concern for an incarcerated
hernia. However, it is uncommon for a hernia to appear in the presence of a
communicating hydrocele because of the narrowness of the patent processus
vaginalis that is associated with the hydrocele. The acute hydrocele presents only
in the scrotum but may extend superiorly toward the inguinal canal. With a

hydrocele, however, no mass should be palpable up the inguinal canal at the level
of the internal ring.
Management. Unless the child is ill with signs of intestinal obstruction or toxic
from a gangrenous bowel, a manual reduction of the incarcerated hernia should