Atypical Obstructions: What Do Emergency Providers Need to Know About Incarcerated and Strangulated Hernia, Closed Loop Obstruction, Volvulus, and Internal Hernia? What Is the Prognostic Value of a Lactate?

  • Jessie Werner
  • Jane Preotle


Internal hernia, volvulus, and closed loop bowel obstruction have a particularly high morbidity and mortality. All can occur in patients without a surgical history and are important to include in the differential diagnosis of abdominal pain and vomiting. Closed loop bowel obstructions, which can be due to internal hernias, are more prone to bowel strangulation and are considered a surgical emergency. In incarcerated hernia, time from symptom onset to surgery is important in patient outcomes, particularly in patients with symptoms >8 h, comorbid conditions, high ASA scores, presence of strangulation, and advanced age. While lactic acid is routinely used as a marker for tissue ischemia, it has poor sensitivity and specificity for diagnosing acute bowel injury.


Internal hernia Volvulus Closed loop obstruction Bowel strangulation Lactic acid 


  1. 1.
    Birindelli A, Sartelli M, Di Saverio S, et al. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg. 2017;12:37.CrossRefGoogle Scholar
  2. 2.
    Murphy K, O’Connor O, Maher M. Adult abdominal hernias. AJR Am J Roentgenol. 2014;202(6):w506–22.CrossRefGoogle Scholar
  3. 3.
    Beadles C, Meagher A, Charles A. Trends in emergent hernia repair in the United States. JAMA Surg. 2015;150(3):194–200.CrossRefGoogle Scholar
  4. 4.
    Derici H, Unalp HR, Bozdag AD, Nazli O, Tansug T, Kamer E. Factors affecting morbidity and mortality in incarcerated abdominal wall hernias. Hernia. 2007;11(4):341–6. Scholar
  5. 5.
    Tsumura H, Ichikawa T, Hiyama E, Murakami Y, Sueda T. Systemic inflammatory response syndrome (SIRS) as a predictor of strangulated small bowel obstruction. Hepato-Gastroenterology. 2004;51(59):1393–6.PubMedGoogle Scholar
  6. 6.
    Sarr MG, Bulkley GB, Zuidema GD. Preoperative recognition of intestinal strangulation obstruction. Prospective evaluation of diagnostic capability. Am J Surg. 1983;145(1):176–82. Scholar
  7. 7.
    Icoz G, Makay O, Sozbilen M, et al. Is D-dimer a predictor of strangulated intestinal hernia? World J Surg. 2006;30(12):2165–9. Scholar
  8. 8.
    Kahramanca S, Kaya O, Ozgehan G, et al. Are fibrinogen and complete blood count parameters predictive in incarcerated abdominal hernia repair? Int Surg. 2014;99(6):723–8.CrossRefGoogle Scholar
  9. 9.
    Graeber G, O’Neil J, Wolf R, Wukich D, Caffery P, Harman J. Elevated levels of peritoneal serum creatine phosphokinase with strangulated small bowel obstruction. Arch Surg. 1983;118:837–40.CrossRefGoogle Scholar
  10. 10.
    Tanaka K, Hanyu N, Iida T, et al. Lactate levels in the detection of preoperative bowel strangulation. Am Surg. 2012;78(1):86–8.PubMedGoogle Scholar
  11. 11.
    Spence L, Pillado E, Kim D, Plurad D. Follow-up trends after emergency department discharge for acutely symptomatic hernias. Am J Surg. 2017;214(6):1018–21. Scholar
  12. 12.
    Chick JFB, Mandell JC, Mullen KM, Khurana B. Classic signs of closed loop bowel obstruction. Intern Emerg Med. 2013;8:263.CrossRefGoogle Scholar
  13. 13.
    Kulaylat MN, Doerr RJ. Small bowel obstruction. Surgical treatment: evidence-based and problem-oriented. Zuckschwerdt: Munich; 2001.Google Scholar
  14. 14.
    Paulson E, Thompson W. Review of small-bowel obstruction: the diagnosis and when to worry. Radiology. 2015;275(2):332–42.CrossRefGoogle Scholar
  15. 15.
    Gingold D, Murrell Z. Management of colonic volvulus. Clin Colon Rectal Surg. 2012;25(4):236–44.CrossRefGoogle Scholar
  16. 16.
    Scharl M, Biedermann L. A symptomatic coffee bean: acute sigmoid volvulus. Case Rep Gastroenterol. 2017;11(2):348–51.CrossRefGoogle Scholar
  17. 17.
    Gündeş E, Akgul N, Mazican M, Aday U, Cetin DA, Ciyiltepe H. Acute abdomen in a mentally retarded patient: cecal volvulus. Prz Gastroenterol. 2017;12(2):159–61.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Kar S, Mohapatra C, Rath PK. A rare type of primary internal hernia causing small intestinal obstruction. Case Rep Surg. 2016;2016:3540794.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Martin L, Merkle E, Thompson W. Review of internal hernias: radiographic and clinical findings. Am J Roentgenol. 2006;186(3):703–17.CrossRefGoogle Scholar
  20. 20.
    Al-Mansour MR, Mundy R, Canoy JM, Dulaimy K, Kuhn JN, Romanelli J. Internal hernia after laparoscopic antecolic Roux-en-Y gastric bypass. Obes Surg. 2015;25(11):2106–11.CrossRefGoogle Scholar
  21. 21.
    Mancuso N, Sweeney M. The sick bowel obstruction patient [Internet]. 2017 [cited 2017 Sept 24]. Available from:
  22. 22.
    Lange H, Jäckel R. Usefulness of plasma lactate concentration in the diagnosis of acute abdominal disease. Eur J Surg. 1994;160(6–7):381–4.PubMedGoogle Scholar
  23. 23.
    Demir IE, Ceyhan GO, Friess H. Beyond lactate: is there a role for serum lactate measurement in diagnosing acute mesenteric ischemia? Dig Surg. 2012;29(3):226–35.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Jessie Werner
    • 1
  • Jane Preotle
    • 1
  1. 1.Department of Emergency MedicineAlpert Medical School of Brown UniversityProvidenceUSA

Personalised recommendations