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Ultrasound and inguinal hernia - Ärzteforum

Post#1 »

Dear collegues,
around here ultrasound is very popular among family physicians and radiologists for diagnosing inguinal hernias. In our hospital, we think it does add anything. Does anybody use it, routinely or in dubious cases?
Some ideas from around the globe, please!

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Old surgeon

Re: Ultrasound and inguinal hernia - Ärzteforum

Post#2 »

Regarding your query about using U/S to diagnose hernia-- Not only is it of unproven efficacy and accuracy to my knowledge, but it represents something abhorrent to me when I see physicians trying this junk--it represents physicians becoming less and less attached to their patients, and more attached and dependent on toys, gimmicks devices, etc--it represents physicians simply no longer understanding physical examination, or the anatomy and physiology of the groin. Not that U/S is not a valuable tool for many things, but not for something like a hernia, which is totally-and I'm sorry, but this is true--and completely diagnosable by physical exam alone. It's a shame when nonsurgeons who used to be able to diagnose hernias, like family practitioners, lose this skill, but when surgeons also do this, then it is abhorrent, and a disservice to your patients. Another problem with U/S in this setting is that it will show a whole variety of things which are better left undetected, especially by those who use U/S for this purpose, who by definition do not understand groin anatomy--inguinal nodes, small "lipomas of the cord", small varicoceles, Mullerian duct or Wolffian cysts of the vas or epidydimis, etc, etc, which as sure as I'm typing this now will then lead to more tests, CT's, and urgent consults--all for nothing! If even a half of the effort and expense used in the irrational enthusiasm and mania for these gimmicks were applied to practicing medicine--that is, to guiding and educating these docs in --horrors--anatomy, surgical indications, reading a book, etc--our patients would be so much better offf--but of course radiologists and family docs, etc, would then not have as much in the way of reimbursable charges--and there, my friend, is the real crux of the problem. A case will follow in a post I'm about to make to the net to further illustrate this terrible problem with inability to understand or diagnose hernias.

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Old surgeon

Re: Ultrasound and inguinal hernia - Ärzteforum

Post#3 »

A case to illustrate the increasing inability of physicians to understand or diagnose hernias: A true story (maybe some of you enterprising members can write a screenplay from this--Hernia! The Movie):

A 78 yo female showed up in a nameless ER 3/25 complaining of headache, "chest pain" and nausea and vomiting, altho the lady herself later claimed she never had headache, only increasing weakness, nausea and vomiting. The ER note, and subsequent admission H&P to family practice, documented a 5x5 cm right inguinal "mass" or "tender adenopathy", which patient claimed had been present for the past 2 weeks and was becoming increasingly tender. On P.E. the abdomen was noted to be "tender" and distended with diminished bowel sounds--admission diagnosis--"R/O MI". Over the next TWO DAYS they proceeded to get a few EKG's and a few runs of cardiac enzymes (all normal), not making much of her continued vomiting (treated with the magic pill--er, I mean phenergan) or her failure to pass any flatus or bowel movement, and an absence of any urine output for two shifts (16 hours). 48 hours after admission, the first attending Family Practice note appears on the chart, after morning rounds on 3/27 at 10am, noting again a tender R inguinal mass, abdominal distention and "rebound" and absent bowel sounds, and diminished mental status--his assessment that surgery should be consulted(it is clear he also did not have any understanding what was happening, just that the patient looked sick and it appeared to be from her belly) was not actually done until 2pm, because of course a CT of the head and flat and uprite abdominal X-rays first had to be gotten. Our second year junior surgery resident then saw the patient, within one minute called me and said she had an incarcerated, probably strangulated inguinal hernia (i.e. this was not a difficult call), X-rays showed dilated smal bowel loops with air-fluid levels and no air in the colon, abdomen had rigid peritonitis, CT head was normal (really?), and there was heat and erythema over the swollen tender right groin. No fever, WBC that am was 2.3K. A foley catheter was placed and it produced a little fogging with a drop or two of brownish jelly(I.e. very concentrated and scant urine)

The patient was lethargic but nonetheless had enough together to categorically refuse surgery--family was called and her next of kin daughter also refused surgery for her over the phone, but were on their way in. Meanwhile we suggested starting another couple IV's to supplement her indwelling 20g catheter with KVO fluids, and started pouring fluids into her. At 5pm, she dropped her blood pressure to 70/40, pulse 150, although urine had picked up--at least by now had turned back to liquid consistency. Antibiotics were empirically started in anticipation fo family consenting to surgery. But when daughter arrived, she still refused surgery, and mother by now was unresponsive--bloood gas showed pH 7.06, pCO2 70, pO2 100 We brought her up to the ICU, placed a Swan-Ganz catheter (sorry surgeon, but do believe it would help here in assessing endpoints for resuscitation) and intubated her.

As I predicted when patient initially refused surgery--it's uncanny how predictable these cases always are--the daughter finally consented at 11pm when patient was starting to see St. Peter (he guards the heavenly gates for us Catholics, surgeon), and we had her in recovery room by 12:30am. Laparotomy showed liters of watery brown fluid without odor and a necrotic loop of mid-jejunum with both open ends waving in the breeze, obviously having fallen out of the very tight hernia--we did a quick stapled anastomosis--the proximal limb wasn't very distended, as obviously it had decompressed its contents over the last few hours--and closed the hernia sac with a purse string from inside the abdomen. There was no solid debris and no exudate or walling off of the spillage, suggesting to us it had been around for only a few hours. No other pathology found. We sucked out all fluid, washed the remainder with only about a liter of saline, closed the abdomen, left the skin open, then I opened up the groin to expose the canal because of the obvious contamination that must have happened in the inguinal tissues--no obvious evidnec of contamination or infection there, and we packed that open too. Over the next 2 days, she was quite unstable with a clincal picture of SIRS--no fever, WBC only reached 10K, but sequestered large volumes(we were as much as 12 liters ahead on day 2), and ended up on hi doses of dopamine and epinephrine to maintrain pressures of 70-80mmHg. She became oliguric on day 2 and we were ready for renal shutdown, but renal function never did deteriorate, and on day 3 she began a spontaneous diuresis, lung compliance dramatically improved, and today on 15ug/kg dopamine and off dopamine and all maintenance fluids has a cardiac index of 4.0, PCWP 12, BUN 18, Creat 0.9, pH 7.34, pCO2 43, pO2 on 40% FIO2 100, and urine output 100-150cc/hr. She looks great!

Now--besides the obvious issue of delayed diagnosis--for those with comments, address how you would handle her antibiotics.

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Re: Ultrasound and inguinal hernia - Ärzteforum

Post#4 »

I will make the following comments:

(1) I am not at all surprized by the care delivered by our cognitive primary care provider collegues. I am a little surprized, however, that they did not tell you to do the case laparoscopically. You know, your patient was sick and surgery is bad.

(2) Antibiotics: by your description, the patient did not have secondary bacterial peritonitis. Therefore, I would give antibiotics for 24 hours.

(3) I would not have used a pulmonary artery catheter, at least initially. I would have given large volume crystalloid resuscitation. If she did not respond, and inotropes appeared to be indicated, then I would use the PA catheter to measure cardiac output (I do not have good data to justify this statement). I think the data from multiple studies show that there is no survival benefit from using PA cath derived parameters in guiding the end point of resuscitation. I think Gattinoni's study is one of the better ones.

Pediatric surg

Re: Ultrasound and inguinal hernia - Ärzteforum

Post#5 »

I had interesting experience with early found hematomas deeply in inguinal tissues post operation on hernias in ultrasound.

Remember also some cases of renal abnormalities in children with hernias.

In many "not clear" inguinal lumps US can be helpful, for sure: does not make any side effects and its cheap.


Re: Ultrasound and inguinal hernia - Ärzteforum

Post#6 »

Unfortunately this whole scenario also happens on this side of the Atlantic as well.

In the UK no radiology department that I have worked in will let us perform an erect abdo film. They state that it yields no more information that an erect chest X-ray and supine abdo. Said to be unnecessary irradiation.

Not sure of the evidence but this has been standard practice for a while now and I must say I don't have any great problems with this policy.

Any comments?

As an aside do over-investigating doctors get sued in the litigious USA for ordering unnecessary x-rays?

John Dissector

Re: Ultrasound and inguinal hernia - Ärzteforum

Post#7 »

I agree with this surprisingly enlightened policy of your radiologists in most cases, altho there are scattered instances in which uprite films will confirm a clinical picture of bowel obstruction, though admittedly won't add much to the supine films. The plain abdominal X-ray is the most useless, and therfore among the most unnecessarily - ordered tests in the field of medicine. It has the lowest yield of any other imaging study, and is routinely gotten to make the doctor, not the patient, feel better. I congratulate your radiologists for taking up the challenge of trying to get their colleagues to be more rational in the use of tests, altho it is inexplicably like moving a mountain to get docs to STOP ordering "tests". One interesting contrast, though, is why you would never see radiologists do that here in the States, and the answer is simple--the radiologists here get paid for every X-ray ordered, so who in the world cares if it is not indicated? I hope nobody really thinks that cost-effectiveness and what's best for the patient is more motivating than money? In socialized systems, it is in the radiologists' interests to cut costs, rather than expand them, which is much more consistent with good medicine as well.

No, we don't get sued for unnecessary testing, for a simple reason--it is not negligence to do so, and docs can get sued only for negligence, which prompts many to falsely believe(as clearly refuted in numerous studies) that they can protect themselves by getting more tests--and the cascade rolls ever onward, only able to be stopped by the medical community developing some common sense rather than being motivated by their own wallets. I would totally be in favor, though, of some system of making us accountable for unnecessary tests, in the same way as we at the Univ Fla Jax hold our own residents accountable every day for every test or x-ray they order--how about the doc, rather than the exploited patient, be made to pay for every test themselves which they can not justify? Again, when you hit our own wallets, watch the great results--unfortunately, we seem to be far past being motivated by what's merely right or beneficial for the patient--Hippocrates, Albert Schweitzer, Father Damien are now simply dim figures from history. What they stood for is forgotten.

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Lady Surgeon

Re: Ultrasound and inguinal hernia - Ärzteforum

Post#8 »

No. Not unless there is a complication directly related to the xray (i.e. stroke during a carotid arteriogram).

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A Doctor

Re: Ultrasound and inguinal hernia - Ärzteforum

Post#9 »

No, this is one of my pet peeves also. The 2 that irritate me the most are the countless plain abdominal X-rays obtained as part of a work-up for appendicitis in a young healthy child or adult and the countless sonograms obtained after pelvic exam shows a markedly enlarged uterus, especially the uteri that extend halfway or more up to the umbilicus.

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