Clinical Types of Hernia

Inguinal Hernia (Right sided)

Abdominal hernias are the most common hernias of the human body.

Reducible Hernia:

In this type of abdominal hernia, the contents contained in the hernial sac can be returned into the abdominal cavity, but the sac remains in its position. In other words, reducible hernia is an uncomplicated hernia.

Irreducible Hernia:

In this type of abdominal hernia, the contents of the hernial sac can not be returned to the abdomen assuring that there is no other complications. Irreducibility of hernia can be caused by adhesions of the hernia contents to each other or with the sac, adhesion of one part of sac to the other, sliding hernia and large scrotal hernia.

Irreducible hernia is often confused with strangulated hernia by the newcomer trainees. Clinically a strangulated hernia is also an irreducible hernia, but it is extremely tender and tense and moreover overlying skin may be seen red. These typical signs of strangulated hernia are absent in the patients with reducible hernia.

Obstructed or incarcerated hernia:

Irreducible hernia associated with intestinal obstruction provided that there is no interference with the blood supply is called obstructed hernia. Bear in mind, strangulated hernia also possess two features of obstructed hernia (irreducibility, intestinal obstruction), but it also interferes with blood supply of the intestine. Obstructed hernia does not possess the third feature of strangulated hernia (blood supply compromised or arrested).

Strangulated hernia:

Patient with Obstructed Umbilical Hernia and Meleney's Gangrene

An irreducible hernia that causes intestinal obstruction and arrest of blood supply to the contents is called strangulated hernia. Diagnosis of strangulated hernia is made when it is irreducible, without any impulse on coughing, extremely tender and tense. Strangulated hernia is an emergency and needs immediate surgery.

Inflamed hernia:

The hernia having inflamed viscera (appendicitis, salpingitis, Meckel’s diverticulitis) in its sac is called inflamed hernia. Inflamed hernia is seen with red edematous overlying skin, painful swelling that is tender. Inflamed hernia can be differentiated from the strangulated hernia as it is not tense and does not have the feature of intestinal obstruction.

Sliding hernia, Richter’s hernia, Litre’s hernia and Maydl’s hernia (hernia-en W) are other rare varieties of hernia.

Overview:

Reducible hernia: Simple and can be reduced + No other complication
Irreducible hernia: Simple but can not be reduced + No other complication
Obstructed hernia: Irreducible + Intestinal obstruction
Strangulated hernia: Irreducible + Intestinal obstruction + arrested blood supply + Tense and Tender
Inflamed hernia: Red, painful and tender swelling + Not tense

Free Air under Diaphragm

Free air under diaphragm means air seen on simple chest x-ray taken in the erect position (standing or upright position) of the patient. As per medical joke, it is not ‘free air’, it costs a lot or results expensive. For this free air under diaphragm, immediate surgical intervention (mostly exploratory laprotomy) is indicated. And, this is so called ‘free air’ that causes the poor patient to undergo a big operation (exploratory laprotomy).

Most of the time, the cause of this free air under diaphragm is the perforated abdominal viscus. It means free air itself is not fatal, but the factual reason behind it is dangerous as along with the free air leaking out enteric content is deadly. Perforation of stomach or duodenum happens to occur due to peptic ulcers that leak out. Perforation of small intestine is less common and may result from inflammatory conditions like Crohn’s disease or cancers. However, perforation of colon is relatively more common and it may result from diverticulitis.

In nutshell, the differential diagnosis of air under diaphragm is as follows:

• Perforated peptic ulcer (most common)
• Ruptured diverticulitis (colon)
• Abdominal trauma
• Perforated cancer (colon)
• Esophageal tear (Boerhaave's syndrome)
• Perforated cancer of stomach
• Abdominal instrumentation

Again a medical joke, you call it free air while it is under the diaphragm. It means that there are not two or three air bubbles but a large collection of air under diaphragm.

Varicose Veins: A Short Review

Introduction to varicose veins:

Varicose veins are usually seen in lower limbs of the individuals who use to stand for longer hours. Varicose veins can be defined as “Dilated, tortuous and elongated veins caused by reversal of blood flow through faulty valves.”

Types of varicose veins:

These include long sephenous vein varicosity, short sephenous vein varicosity, varicose veins due to perorator incompetence, thread veins, reticular varices and the combination of these types.

Sites varicose veins:

Varicosities can occur in lower limbs, pampiniform pexus of veins, vulva and at the sites of portosystemic anastomosis such as esophagus and around the umbilicus.

Clinical features of varicose veins:

Clinical features include swelling of leg, dragging pain, heaviness in the legs, night time cramps, oedema feet, discoloration, ulceration in the feet and painful walk.

Tests for varicose veins:

Brodie-Trendelenburg test, Perthe’s test, three tourniquet test, Schwartz test, Pratt’s test, Morrissey’s cough impulse test, Fegan’s test, Ian Airid test are used to diagnose varicose veins. Abdominal examination is necessary to rule out the cause of varicose veins such as pelvic tumors, lymph nodes which may compress the veins.

Investigations:

Venous Doppler, Duplex scan, venography, plethysmographyAVP (Ambulatory Venous Pressure, Ultrasound abdomen, plain x-ray and varicography can be advised in order to know the condition of varicose veins.

Differential Diagnosis of varicose veins:

Differential Diagnoses of varicose veins include lymphoedema, arteriovenous malformation, orthostatic oedema, renal or cardiac disease, hepatic disorders.

Treatment of varicose veins:

Elastic crepe bandage application, Diosmin therapy, elevation of limb and Unna boots are the practical conservative treatment of varicose veins. Among drugs, calcium dobesilate (500mg BD), Diosmin (450 mg BD), toxerutin (500mg BD) can improve the capillary dynamics.

Moreover, injection sclerotherapy and surgery are the other treatments of varicose veins. Stripping of veins is the common surgical procedure being done for varicose veins.

Complications of Varicose veins:

Varicose veins may bleed, can cause eczema and dermatitis, and may produce venous ulcers. Periostitis, Marjolin’s ulcer, lipodermatosclerosis, DVT, calcification and thrombophlebitis are the other complications of long standing varicose veins.