= Solution
\b[Suspected strangulation means threatened or impaired blood supply to herniated tissue; it is more serious than irreducibility alone and can occur without complete intestinal obstruction.] The diagnostic assessment must combine the local swelling, abdominal symptoms, general condition and time course.
Ask about a previous <hernia>, whether it was reducible, a new painful swelling, abrupt failure of reduction, the onset of pain and <vomiting>, bowel function and prior attempts at manipulation. Examine the relevant sites, including both groins and the femoral regions, rather than attributing unexplained <vomiting> and abdominal pain solely to a gastric illness. A previously familiar painless lump can become dangerous after years of intermittent reduction. A small femoral <hernia> may be less conspicuous than its systemic consequences suggest.
Locally, new tenderness, tension, irreducibility and loss of a usual cough impulse raise concern. Erythematous or discoloured overlying skin is more alarming, but can be absent early. Abdominal distension, persistent <vomiting> and failure to pass stool or flatus support <intestinal obstruction>. Increasing pain, <tachycardia>, <fever>, dehydration, <peritonitis> or shock suggest advancing compromise. Do not wait for every late sign: prolonged delay can lead to <intestinal ischaemia>, <necrosis> and <sepsis>.<WSES guidelines for emergency repair of complicated abdominal wall hernias (2017)>[Timing of intervention; predictors and consequences of bowel strangulation]{ref}
Several negative observations are unsafe reassurances. Passage of stool may merely empty bowel below the obstruction. If only part of the bowel wall is trapped, as in a <Richter hernia>, complete obstruction may never occur. A very ill person may describe less pain late in the course. Disappearance of the external swelling after a forceful manipulation does not prove safe restoration of viable bowel: persistence of pain or obstruction demands reassessment, including possible <reduction en masse>.<Management of Incarcerated and Strangulated Abdominal Wall Hernias by the American College of Surgeons>[2021 manual, chapter 23, Richter hernia and diagnostic considerations]{ref}
An 1866 surgeon relied heavily on these bedside features and on the distinction from an inflamed <lymph node>, <hydrocele>, another groin mass or non-strangulated <hernia>. Contemporary reports describe sequences of attempted reduction, baths, enemata and <chloroform> before operation. They document period practice; they must not be transferred into a rule that strangulation begins only when repeated reduction has failed.<Surgical ward clinical report from the Royal Infirmary (1864–1865)>[Published 1866, p. 329, historical taxis and operative decision sequence]{ref}
\b[Modern correction: suspected strangulation needs immediate surgical assessment and timely operative treatment.] Selected <blood tests> and imaging, commonly contrast-enhanced <computed tomography> when useful and feasible, support assessment but should not delay action in a convincing emergency. Normal early laboratory results do not exclude local ischaemia. Current guidance distinguishes an acutely irreducible <hernia> without evidence of bowel compromise, where supervised reduction may be considered, from suspected strangulation, where emergency surgery is indicated. Ongoing symptoms after apparent reduction also require observation and reassessment.<Update of the international HerniaSurge guidelines for groin hernia management (2023)>[Acute groin hernias, manual reduction contraindications, observation and emergency surgery]{ref} The diagnostic goal is not merely to name the lump, but to recognize endangered tissue before irreversible injury.
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