eMedicine Specialties > Emergency Medicine > Gastrointestinal

Hernias: Treatment & Medication

Author: Bret A Nicks, MD, Assistant Professor, Assistant Medical Director, Department of Emergency Medicine, Wake Forest University Health Sciences
Coauthor(s): Kim Askew, MD, Assistant Professor, Department of Emergency Medicine, Wake Forest University School of Medicine
Contributor Information and Disclosures

Updated: Nov 11, 2009

Treatment

Emergency Department Care

  • Reduction of a hernia2,9,15
    • Provide adequate sedation and analgesia to prevent straining or pain. The patient should be relaxed enough to not increase intra-abdominal pressure or to tighten the involved musculature.
    • Place the patient supine with a pillow under his or her knees.
    • Place the patient in a Trendelenburg position of approximately 15-20° for inguinal hernias.
    • Apply a padded cold pack to the area to reduce swelling and blood flow while establishing appropriate analgesia.
    • Place the ipsilateral leg in an externally rotated and flexed position resembling a unilateral frog leg position.
    • Place 2 fingers at the edge of the hernial ring to prevent the hernial sac from riding over the ring during reduction attempts.
    • Firm, steady pressure should be applied to the side of the hernia contents close to the hernia opening, guiding it back through the defect.
    • Applying pressure at the apex, or first point, that is felt may cause the herniated bowel to "mushroom" out over the hernia opening instead of advancing through it.
    • Consult with a surgeon if reduction is unsuccessful after 1 or 2 attempts; do not use repeated forceful attempts.
    • The spontaneous reduction technique requires adequate sedation/analgesia, Trendelenburg positioning, and padded cold packs applied to the hernia for a duration of 20-30 minutes. This can be attempted prior to manual reduction attempts.
    • Also see Hernia Reduction.

Consultations

Consult a surgeon for the following reasons:1,16,3

  • Inability to reduce the hernia
  • Concern for a strangulated bowel and a patient with a toxic appearance
  • Patients with comorbid risks for sedation should have a surgeon present for the initial reduction attempt

Medication

For strangulated hernias, start broad-spectrum antibiotics. Antibiotics are administered routinely if ischemic bowel is suspected.

Antibiotics

These agents are to be used if the patient has a strangulated hernia.


Cefoxitin (Mefoxin)

Multiple regimens that cover for bowel perforation and/or ischemic bowel can be used. Cover for both aerobic and anaerobic gram-negative bacteria.

Adult

1-2 g IV q8h

Pediatric

80 mg/kg/d IV divided into 4 equal doses q6h

Probenecid may increase effects; aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in previously diagnosed colitis

More on Hernias

Overview: Hernias
Differential Diagnoses & Workup: Hernias
Treatment & Medication: Hernias
Follow-up: Hernias
Multimedia: Hernias
References
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References

  1. Eubanks S. Hernias. In: Sabiston DC Jr, ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 1997.

  2. Katz DA. Evaluation and management of inguinal and umbilical hernias. Pediatr Ann. Dec 2001;30(12):729-35. [Medline].

  3. Levine BJ, Nabha S, Bouzoukis JK. Chronic inguinal hernia. J Emerg Med. May-Jun 1999;17(3):515-6. [Medline].

  4. Matthews RD, Neumayer L. Inguinal hernia in the 21st century: an evidence-based review. Curr Probl Surg. Apr 2008;45(4):261-312. [Medline].

  5. Scherer LR 3d, Grosfeld JL. Inguinal hernia and umbilical anomalies. Pediatr Clin North Am. Dec 1993;40(6):1121-31. [Medline].

  6. Bobrow RS. The hernia. J Am Board Fam Pract. Jan-Feb 1999;12(1):95-6. [Medline].

  7. Wants GE. Abdominal wall hernias. In: Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery. 6th ed. 1994.

  8. Mensching JJ, Musielewicz AJ. Abdominal wall hernias. Emerg Med Clin North Am. Nov 1996;14(4):739-56. [Medline].

  9. Manthey DE. Abdominal hernia reduction. In: Clinical Procedures in Emergency Medicine. 2003.

  10. Brandt ML. Pediatric hernias. Surg Clin North Am. Feb 2008;88(1):27-43, vii-viii. [Medline].

  11. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am. Jun 1993;73(3):413-26. [Medline].

  12. Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am. Dec 1998;78(6):941-51, v-vi. [Medline].

  13. Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am. Aug 1998;45(4):773-89. [Medline].

  14. Akbulut S, Cakabay B, Sezgin A. A familial tendency for developing inguinal hernias: study of a single family. Hernia. Aug 29 2009;[Medline].

  15. Smith S. Inguinal hernia reduction. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:840-847/87.

  16. Ginsburg BY, Sharma AN. Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med. Feb 2006;30(2):155-7. [Medline].

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Further Reading

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Keywords

hernia, hernia symptoms, hernia treatment, hernia causes, abdominal wall hernia, indirect inguinal hernia, indirect hernia, direct inguinal hernia, direct hernia, femoral hernia, umbilical hernia, Richter hernia, incisional hernia, spigelian hernia, obturator hernia, reducible hernia, incarcerated hernia, strangulated hernia

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Contributor Information and Disclosures

Author

Bret A Nicks, MD, Assistant Professor, Assistant Medical Director, Department of Emergency Medicine, Wake Forest University Health Sciences
Bret A Nicks, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Christian Medical & Dental Society, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Kim Askew, MD, Assistant Professor, Department of Emergency Medicine, Wake Forest University School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard Lavely, MD, JD, MS, MPH, Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine
Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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