Suspected strangulated inguinal hernia with bowel obstruction — MRCEM SBA MCQ

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EasyGastrointestinal and surgical emergenciesSuspected strangulated inguinal hernia with bowel obstructionMRCEM SBA

A 63-year-old man attends the emergency department with six hours of constant left groin pain. A previously reducible inguinal hernia is now irreducible and very tender, with purple discolouration of the overlying skin. He has vomited twice and has not passed flatus since the pain began. His pulse is 108/min and blood pressure is 136/78 mmHg. Intravenous fluids and analgesia have been started. What is the most appropriate next management plan?

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Correct answer: D — Arrange immediate surgical assessment for emergency operative management.

The new irreducibility and marked tenderness, together with vomiting and failure to pass flatus, indicate a complicated hernia with bowel obstruction. Purple skin discolouration raises concern for strangulation. This requires immediate assessment by the on-call surgical team for emergency operative management while resuscitation continues. A normal blood pressure does not exclude threatened bowel. UK clinical guidance directs emergency referral for an obstructed or strangulated hernia. ([hweclinicalguidance.nhs.uk](https://www.hweclinicalguidance.nhs.uk/all-clinical-areas-documents/download?checksum=3576545c35c6c0022fad2920380240b9&cid=5198&document=22&field=1)) A is attractive because CT can help when the diagnosis is uncertain, but the clinical findings already warrant surgical assessment; imaging should not be a prerequisite to calling the team. B is a potential approach to a recently irreducible inguinal hernia *without* signs of strangulation, not one with skin discolouration and obstructive symptoms. ([hweclinicalguidance.nhs.uk](https://www.hweclinicalguidance.nhs.uk/all-clinical-areas-documents/download?checksum=3576545c35c6c0022fad2920380240b9&cid=5198&document=22&field=1)) C may relieve vomiting but cannot replace or delay assessment of potentially ischaemic bowel. E would allow time for deterioration in a patient who already meets criteria for emergency, rather than deferred, surgical referral. ([hweclinicalguidance.nhs.uk](https://www.hweclinicalguidance.nhs.uk/all-clinical-areas-documents/download?checksum=3576545c35c6c0022fad2920380240b9&cid=5198&document=22&field=1))

Reference: Abdominal Hernias – Adults (Not stated; checked 27 September 2026) — https://www.hweclinicalguidance.nhs.uk/all-clinical-areas-documents/download?checksum=3576545c35c6c0022fad2920380240b9&cid=5198&document=22&field=1 Repair of Minimally Symptomatic Inguinal Hernia Policy (June 2025) — https://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical-Policies/Clinical_Policies/PLCV/general_surgery/Repair_of_Minimally_Symptomatic_Inguinal_Hernia.pdf Hernia: Inguinal Hernia (Not stated; checked 27 September 2026) — https://www.ncic.nhs.uk/patients-visitors/patient-information-leaflets/Hernia-Inguinal-Hernia/submit/96049