A hernia occurs when an internal organ or tissue pushes through a weak spot in the surrounding muscle or tissue wall. While many people associate hernias with the groin, they can occur in various locations across the abdomen. The upper abdomen, near or under the ribs, is where two distinct types of hernias commonly develop. This happens due to weaknesses in the abdominal wall or the muscle separating the chest and abdominal cavities.
Understanding Upper Abdominal Hernias
The two main types of hernias that appear in the upper abdomen are the hiatal hernia and the epigastric hernia. An epigastric hernia forms in the midline of the abdominal wall, specifically between the breastbone and the belly button (the epigastrium). A gap in the connective tissue called the linea alba allows abdominal fat or tissue to protrude. This type of ventral hernia manifests as a small, palpable lump just below the ribcage along the center of the body.
A hiatal hernia is structurally different, involving the diaphragm, the large muscle separating the chest cavity from the abdomen. The diaphragm has a small opening, called the hiatus, through which the esophagus passes to connect to the stomach. A hiatal hernia develops when part of the stomach pushes upward through this enlarged hiatus into the chest area. This protrusion occurs directly beneath the lower ribs, causing upper abdominal and lower chest discomfort.
Unlike the epigastric hernia, a hiatal hernia is not visible externally because it is an internal protrusion into the chest cavity. These hernias are classified into two main types. The more common is the sliding hiatal hernia, where the top of the stomach slides up and down through the hiatus. The less common is the paraesophageal hernia, where a part of the stomach rolls up alongside the esophagus.
Recognizing the Specific Symptoms
Symptoms from upper abdominal hernias vary depending on the type and size of the protrusion. An epigastric hernia often presents as a noticeable bulge in the upper center of the abdomen, which becomes more prominent when a person strains, coughs, or stands up. Pain is typically a dull ache or a sharp pain at the site of the bulge, often worsening with physical activity or strain.
Symptoms from a hiatal hernia are commonly related to digestive issues because they involve the stomach migrating into the chest. These include heartburn (a burning sensation in the chest) and regurgitation of food or sour liquid back into the throat. This occurs because the hernia weakens the barrier between the stomach and the esophagus, allowing stomach acid to flow upward.
Individuals with a hiatal hernia may also experience chest pain, difficulty swallowing, or a persistent feeling of fullness soon after eating. If a hernia becomes incarcerated or strangulated, symptoms can rapidly escalate to severe, sharp pain, accompanied by nausea and vomiting. Severe symptoms require immediate medical attention.
Causes and Contributing Risk Factors
Upper abdominal hernias develop when muscular weakness combines with increased pressure in the abdominal cavity. The abdominal wall or diaphragm can weaken naturally due to aging or congenital defects. This weakness creates an opening for tissue to push through. Factors that raise intra-abdominal pressure increase the risk, such as chronic, heavy lifting or persistent coughing due to smoking or respiratory conditions.
Obesity and pregnancy increase intra-abdominal pressure by placing sustained weight and tension on surrounding tissues. Chronic constipation, which leads to frequent straining during bowel movements, also contributes to hernia formation. For hiatal hernias specifically, the diaphragm muscle can weaken with age, making it easier for the stomach to push through the hiatus.
Medical Diagnosis and Treatment Options
A medical professional typically diagnoses an upper abdominal hernia through a physical examination, often by feeling for a bulge or asking the patient to cough. Since hiatal hernias are internal, imaging tests are necessary to confirm the diagnosis. Common diagnostic tools include:
- Abdominal ultrasound
- CT scan
- Upper endoscopy
- Barium swallow (where a patient drinks a liquid to coat the digestive tract for X-ray visualization)
The treatment approach depends on the hernia type, its size, and the severity of the symptoms. Small, asymptomatic epigastric hernias may be managed with watchful waiting and regular check-ups. Surgery, known as a hernioplasty, is the only way to repair an epigastric hernia, typically involving sewing the weak spot closed and sometimes using a mesh patch for reinforcement.
For hiatal hernias, initial management focuses on lifestyle changes and medication to control acid reflux symptoms. Antacids or proton pump inhibitors (PPIs) are prescribed to reduce stomach acid production. If the hiatal hernia is large, a paraesophageal type, or does not respond to medication, surgical repair is necessary to pull the stomach back into the abdomen and tighten the hiatus opening.