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You are called to see a 50-year-old man with a 2-day history of right scrotal swelling and increasing abdominal pain, nausea and vomiting. He is tachycardic and tachypnoeic. He has a history of a left open inguinal hernia repair 10 years ago and has recently started doing weightlifting at the gym. He was at the gym when the pain started.
On examination he has a swollen scrotum on the right side and abdominal distention. Palpation reveals general abdominal and testicular tenderness and there are increased bowel sounds on auscultation. When assessing the scrotal swelling you cannot reduce the swelling when the patient lies down and cannot palpate the testis. When standing, you cannot get above the swelling and it does not transilluminate.
1. What is the most likely diagnosis?
Inguino-scrotal incarcerated hernia with acute bowel obstruction.
2. What test would you carry out to confirm this diagnosis?
A scrotal ultrasound or CT scan will confirm the presence of bowel in the scrotum. An abdominal X-ray may show features of bowel obstruction and sometimes bowel in the scrotum if there is an air level.
3. What is the pathological basis of this disorder?
Weakening of the groin muscles combined with increased abdominal pressure during weightlifting.
4. What might happen next to this man if he is not treated?
Strangulation of the bowel within the inguinoscrotal hernia can lead to ischaemia, bowel perforation, sepsis and death.
5. What treatment will you offer this patient?
Full clinical assessment according to the CRISP (care of the critically ill surgical patient) guidelines, fluid resuscitation, analgesia and a nasogastric tube insertion for small bowel decompression. He will need an urgent review by a general surgeon for surgery.