The abdominal wall is made up of skin, muscles,fat and connective tissue. It does not have the protection of bones like the chest cavity has with the ribcage. This lack of rigidity can lead to small outpouchings known as hernias. It occurs with high pressure within the abdomen especially when the abdominal wall is weak at certain areas. Sometimes an abdominal organ can become trapped within these pouches with varying consequences. Bowel strangulation is considered to be the most serious complications.
What is bowel strangulation?
Bowel strangulation is where a portion of the intestines (bowels) become trapped in a hernia and the blood supply this trapped portion is cut off. The bowel tissue can die leading to serious complications and even death if medical treatment is not forthcoming. The correct term for this condition is a strangulated hernia. The condition is very painful and it should not left untreated as it can prove to be fatal within a very short period of time.
Although abdominal hernias are relatively common, a strangulated hernia rare. It can affect both adults and babies. In infants with hernias, only about 1 to 2 out of 10 end up be a strangulated hernia. However, certain hernias in infants do not need to be treated if it is uncomplicated and the hernia can resolves on its own. Strangulated hernias are considered to be a surgical emergency. There is no way of treating it if the hernia cannot be pushed back.
Causes of Bowel Strangulation
It is important to understand why abdominal hernias occur. Firstly there are different types of hernias.
- Inguinal hernias are common among men. It arises in the region where the lower abdomen continues to the groin.
- Femoral hernias are lower own from incisional hernias. It is more common among women.
- Incisional hernias occur at the site of previous wound or scar.
- Umbilical hernias occur around the belly button (umbilicus) while paraumbilical hernias occur above the belly button.
Hernias arise when the abdominal wall is weakened at one spot. This can occur with abnormal closing of the abdominal wall after birth and is more common in preterm babies or with low birth weight. However, the weakening can also occur in adulthood. Increased pressure within the abdomen particularly when it is sustained is one of the main reasons. Persistent coughing, repeatedly straining during bowel movements, obesity and multiple pregnancies may lead to abdominal wall weakening.
However, sometimes just a few episodes of straining can lead to a hernia if there is prior weakening. People regularly life heavy weights, like weight lifters and people in certain jobs requiring heavy lifting are also at risk. Abdominal surgery or any penetration of the abdominal wall can also lead to weak spots.
Umbilical hernias are less likely to complicate with bowel strangulation as compared to other hernias.
The abdominal wall holds the abdominal organs in. If there is any opening or pouch in the abdominal wall then an organ can slip inside it. The intestines being so long and coiled can easily slip into a hernia and become trapped within it. This is known as an incarcerated hernia. As a result of this entrapment, the bowels are pinched and the contents cannot move through it. In these cases there are symptoms of bowel obstruction are present.
Sometimes the bowel becomes so tightly trapped within the hernia that the blood vessels supply it become compressed. This impedes blood flow to the bowel tissue. When the blood supply is cut off the tissue will die within a short period of time. The trapped portion of the intestine can develop gangrene in as short a period of time as just 6 hours. Tissue death means that the bowel wall can rupture thereby emptying its contents into the abdominal cavity. This will then lead to peritonitis and may eventually progress to shock and even death.
Signs and Symptoms
Since bowel strangulation is a complication of a hernia, it is important to be familiar with the symptoms of an uncomplicated hernia. These symptoms can persist for months or even years before a strangulated hernia arises.
Usually an uncomplicated hernia is painless and there is no tenderness. A bulge may only be seen when straining like during a cough. It is therefore no uncommon that it may be missed in the early stages. The bulging can return to a normal position on its own or by being pushed back. At this stage it is known as a reducible hernia. However, as the condition progresses the bulge cannot be pushed in and it is then known as an irreducible hernia.
Sometimes an uncomplicated and reducible hernia can present with severe pain.
When the bowel is trapped within the hernia but not strangulated then the symptoms of bowel obstruction may be evident. However, it is important to note that these symptoms may not always be present. Other symptoms like pain or tenderness is usually not different between an uncomplicated hernia and an incarcerated hernia. It will be irreducible meaning that the bulge cannot be pushed back in.
The symptoms of a strangulated hernia are usually intense, arise over a very short period of time and continues to worsen. There is severe pain which gradually increases and there is tenderness of the irreducible hernia. In addition, many people will also experience nausea and vomiting. Symptoms of peritonitis and shock arise later.
Treatment of Strangulated Hernia
A strangulated hernia cannot be treated with medication. Antibiotics may be administered but this will not treat the hernia. It requires surgery. A strangulated hernia is considered to be a surgical emergency. A doctor may first attempt a few times to reduce the hernia. The hernia should not be attempted to be forced back as this can reduce any minor blood flow that is keeping the tissue alive. Pain that persists even after the hernia is successfully reduced without surgery may be a sign of a strangulation. Even if the strangulation cannot be confirmed, exploratory surgery is still necessary so that the strangulation can be undone if present.