5 FEBRUARY 2011

Interns Hour

General Data

2 month old maleCalamba, LagunaBorn term via LT CS, twin pregnancy

Chief complaint

Right scrotal mass

History of Present Illness

At 3 weeks of age – noted to have a right inguinal mass, prominent when patient is crying. Mass is reducible when patient is relaxed. No changes in bowel movement, no abdominal distention, no diifficulty urinating. Patient had good suck and activity.

Consult was done at a local hospital and was advised surgery once the patient is older.

At 2 months of age – persistence of above symptoms with noted extension of the mass to the scrotal area. Mass was reducible when palpated. No tenderness, no changes in color noted. No changes in bowel movement, no difficulty urinating, no abdominal distention. Patient had good appetite.

Few hours prior to consult, patient was noted to be crying. Scrotal mass was noted to be enlarged with deviation of the penis to the left side. Noted tenderness. No discoloration noted. No vomiting, no changes in bowel movement, no difficulty urinating. Patient was noted to have poor appetite. Patient was immediately brought to PGH. Hence consult.

Review of systems

• (-) fever, weight loss• (+) rashes, inguinal area, (-) jaundice, pallor• (-) eye pain/discharge, (-) nasoaural discharge• (-) dyspnea, hemoptysis• (-) cyanosis• (-) abdominal pain, diarrhea/constipation• (-) dysuria, hematuria, nocturia• (-) seizures

Prenatal History

Born to a 25 year old motherNo known maternal illnessNo intake of medicationsRegular monthly prenatal check-up at (6x)

LHC

Birth History

Born term via LTCS due to twin pregnancy at St. John Hospital

No known fetomaternal complicationsGood suck, good cry and goo activity

Feeding history

Breastfed up to 1 month of ageStarted drinking formula milk at 1 month of

age (2 cups/ 80ml bottle) Feeds ~8 times a dayNo food preferences

Developmental History

Social smile at 1 month of age

Past Medical History

(+) vaccinations: DPT1, Hepa B1, BCG, OPV1No known illnessesNo allergies to food/drugs

Family Medical History

(+) heart disease(+) similar inguinal mass – twin sibling(-) hypertension(-) PTB(-) Diabetes(-) Bronchial asthma

Personal/Social History

Eldest of twinsLives with parents and grandparents in

bungalow type of house with 2 bedrooms and 1 comfort room

PHYSICAL EXAMINATION

Vital Signs & Anthropometric Measurements

Vital Signs Measures

Heart Rate136 bpm

Length 58 cm

Respiratory Rate

34 cpm Weight 5.41 kg

Temperature 36.8Head

Circumference

37 cm

Abdominal Circumferen

ce37 cm

Chest Circumferen

ce39 cm

Physical Findings

Physical Findings

Primary Working Impression

Inguinoscrotal hernia, incarcerated

Differential DIAGNOSIS

Differential Diagnosis

Findings

Hydrocele (communicating)

Cystic swellingIncrease in size when upright or when intra-abdominal pressure increasesUsually congenitalTransilluminates

Hydrocele (noncommunicatin

g)

Cystic swellingDoes not change in size with changes in position of intra-abdominal pressureOften a simultaneous scrotal abnormality (eg, tumor, epididymitis)Transilluminates

Spermatocele Cystic mass at the upper pole of the testis, adjacent to epididymisTransilluminates

Differential Diagnosis

Findings

Inguinal hernia

Increases in size when upright or when intra-abdominal pressure increasesMay disappear when recumbent or be reducible or compressiblePossibly bowel soundsAbsence of normal spermatic cord structures above the massPossibly palpable in the inguinal canal

Varicocele Palpable when standing, feeling like a bag of wormsUsually on left sidePossibly pain and fullness when standingPossibly testicular atrophy

Hematocele Tender swellingRisk factors (eg, trauma, surgery, bleeding disorder or use of anticoagulants)

Testicular cancer

Mass attached to or part of testisIs solid or does not transilluminatePossibly dull, aching pain or acute pain due to hemorrhage

Hydrocele

accumulation of fluid within the tunica vaginalis

nontendertransilluminates

Hernia

indirect inguinal hernia

Bulge that appears on straining

Bowel sounds may be heard over the hernia

(-) transillumination test

Hematocele

Blood in the tunica vaginalis

Swelling resembles a hydrocele

(-) transillumination test

(+) history of trauma

Spermatocele

painless fluid-filled sac with sperm that is often located above and posterior to the testicle

(+) transillumination test

Inguinal Hernias

Inguinal Hernias

Usually indirect (99%)High incidence in premature infants (30%)Risk for incarceration and strangulation

highest in the 1st year of life (30-40%)

Inguinal hernias

Intra-abdominal contents enter the inguinal region through the patent processus vaginalis

Usually congenital, due to a patent processus vaginalis

Twice as common on the right side

Predisposing Factors

PREMATURITY UROGENITAL   Cryptorchidism   Exstrophy of the bladder

or cloaca   Ambiguous genitalia   Hypospadius/epispadius

INCREASED PERITONEAL FLUID  

Ascites   Ventriculoperitoneal

shunt   Peritoneal dialysis

catheter

INCREASED INTRA-ABDOMINAL PRESSURE  

Repair of abdominal wall defects  

Severe ascites (chylous)   Meconium peritonitis CHRONIC RESPIRATORY

DISEASE   Cystic fibrosis CONNECTIVE TISSUE

DISORDERS   Ehlers-Danlos syndrome   Hunter-Hurler syndrome  Marfan syndrome   Mucopolysaccharidosis

bulge in the inguinal region or extending through the inguinal region into the scrotum or in the upper portion of the labia majora.

most visible at times of irritability or increased intra-abdominal pressure

smooth, firm mass that emerges through the external inguinal ring lateral to the pubic tubercle and enlarges with increased intra-abdominal pressure

“silk glove sign” as the layers of the hernia sac (processus vaginalis) slide over the spermatic cord structures

Incarcerated hernia cannot be reduced into the abdominal cavity small bowel, appendix, omentum, colon, Meckel

diverticulum ovary, fallopian tube irritability, pain in the groin and abdomen, abdominal

distention, and vomiting

Strangulated hernia hernia contents have become ischemic or gangrenous

MANAGEMENT

DIAGNOSTICS

DAIGNOSTIC STRATEGIES

diagnosis of IH in an overwhelming majority of cases is clinical history and examination

If diagnosis cannot be made immediately, the child needs to be re-examined over a period of time to make a definitive diagnosis

Comparative Sp and Sn

TechniqueSensitivi

tySpecificit

y

Physical Exam 74.5 96.3

Ultrasound 92.7 81.5

MRI 94.5 86.3

IMAGING TECHNIQUES

imaging studies are generally not indicatedUltrasonography- can confirm IH in selected

patients not the gold standard for diagnosing IH in children

Gold Standard

Laparoscopy - considered the final means of determining the true groin pathology

Pre-Operation Labs

Complete blood count with differential countblood urea, creatinine, serum electrolytes -

helpful in cases of strangulation and obstruction

Available Labs

Ultrasound: Both testicles are normal with fine homegenous

echogencity, epididymis not dilated No fluid collection in scrotal sac, no mass density

demonstrated Omental structures seen in widened left inguinal

canal with descent upon valsalva

Available Labs

Blood Typing: B PositiveComplete Blood Count

Hemoglobin 107 Hematocrit 0.333

Platelet 443 WBC 15.93

Neutrophils 0.185 Lymphocytes

0.653

Monocyte 0.130 Eosinophils 0.029

Basophils 0.003

Electrolytes Na 142 K 4.4 Cl 102

BUN 5.4 CREA 37

SURGICAL MANAGEMENT

MANAGEMENT

Inguinal hernias do not spontaneously heal and must be surgically repaired because of the risk of incarceration.

Surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.

Application of gentle pressure on the bulge of an inguinal hernia to prevent incarceration until the elective operative repair is performed.

MANAGEMENT: Surgical

Elective herniorrhaphy Involves closing of the patent processus vaginalis indicated to prevent incarceration and subsequent

strangulation Controversy exists regarding the role for exploration

of an asymptomatic opposite side in a child with an inguinal hernia.

Explore only under certain conditions such as in premature infants or in patients in whom incarceration is present.

Management of Incarcerated Hernia

Manual reduction should be attempted if the patient has no signs of systemic toxicity like: leukocytosis, severe tachycardia, abdominal

distention, bilious vomiting, and discoloration of the entrapped viscera

If the patient appears toxic, emergent surgical exploration is necessary.

Management of Incarcerated Hernia

Successful reduction of an incarcerated inguinal hernia results in immediate patient comfort, relief of obstruction, and prevention of strangulation.

Immediate surgery is performed if the reduction is unsuccessful; otherwise, elective operation is scheduled within 24-72 hours after reduction because recurrent incarceration is quite common.

Management of Hernia Strangulation

reduction without operative intervention is not possible

significant swelling from the compromised bowel, the presence of intestinal ischemia secondary to incarceration precludes the possibility of reducing the hernia back into the peritoneal cavity

immediate operative intervention is indicated, and the viability of the intestine must be carefully assessed at the time of surgery

If necrosis has developed, resect the affected segment of bowel

Course of the Patient

Prepared for OR: (maintained on NPO) IVF: D5 IMB @ 23CC/HR started on Cefuroxime (100) 190 mg Q8 Metronidazole (30) 60 mg Q8H

Underwent herniotomy, L under GA High ligation of the hernia sac

Discharge the next day….Take home meds:

1) Paracetamol 0.6 ml every 6H X 2days 2)Amoxicillin 2 drops (100mg/ml) Q6H X 7 days

PROGNOSIS

Inguinal hernias in children recur in less than 1 percent of patients, and recurrences usually result from missed hernia sacs at the fisrt procedure, a direct hernia, or missed femoral hernia.

Overall prognosis is excellent; most patients do extremely well after operative repair of their inguinal hernia.

Mortality is extremely rare but, unfortunately, continues to be reported as a consequence of delayed recognition of an incarcerated and strangulated inguinal hernia.

END