A hernia occurs when a portion of an organ or tissue pushes through a weak spot in the surrounding muscle or fascia, forming a sac that extends beyond the abdominal wall where it should normally be contained. While hernias can appear in various locations, they share the characteristic of tissue escaping its typical confines.
Defining the Condition and Location
An epigastric hernia is a specific type of abdominal wall hernia that develops in the midline of the upper abdomen, known as the epigastrium. This area lies between the bottom of the breastbone and the naval. The condition arises from a defect in the linea alba, a strong, fibrous band of connective tissue running vertically down the center of the abdomen.
The defect allows internal contents to push through, creating a hernia sac under the skin. In most cases, the sac contains pre-peritoneal fatty tissue, the fat layer just beneath the abdominal wall muscles. Less commonly, if the opening is larger, a portion of the intestine may protrude. This weakness can be present from birth or develop over time due to various pressures on the abdominal wall.
Identifying the Symptoms and Causes
The most common sign of an epigastric hernia is a noticeable bulge or lump in the upper abdominal area. The bulge is often more apparent when standing or engaging in activities that increase abdominal pressure, and it may flatten or disappear when lying down.
Pain and discomfort are frequently associated with the condition, often described as a dull ache or a sharp, localized sensation. The discomfort tends to worsen with physical strain, such as coughing, sneezing, lifting heavy objects, or straining during a bowel movement. However, many small epigastric hernias cause no symptoms at all and are discovered incidentally during a routine physical examination.
The root cause is a weakness in the linea alba, which can be congenital or acquired later in life. The protrusion is usually triggered by factors that significantly increase pressure inside the abdominal cavity. Common risk factors include chronic coughing, significant obesity, pregnancy, and activities like heavy lifting or persistent straining due to constipation.
Diagnosis and Management Options
Diagnosing an epigastric hernia typically begins with a thorough physical examination. The doctor will inspect and palpate the upper abdomen to feel for the characteristic bulge and assess tenderness. They may ask the patient to cough or strain, as this action increases intra-abdominal pressure and makes the hernia more prominent.
The provider will also assess if the hernia is “reducible,” meaning the protruding tissue can be gently pushed back into the abdominal cavity. If the diagnosis remains unclear, or if a complication is suspected, imaging tests such as an ultrasound or a computed tomography (CT) scan may be used. These tools help confirm the size of the defect, its precise location, and the contents of the hernia sac.
Management depends heavily on the hernia’s size and the presence of symptoms. For small, asymptomatic hernias, a doctor may recommend watchful waiting. However, since hernias do not heal on their own and carry the risk of enlargement, surgical repair is the only definitive treatment.
Surgical options are divided into two main categories: herniorrhaphy and hernioplasty. Herniorrhaphy involves stitching the edges of the defect in the linea alba back together to close the opening. Hernioplasty is a more common technique where the defect is repaired and reinforced with a piece of synthetic surgical mesh. The mesh strengthens the weakened abdominal wall, significantly reducing the risk of recurrence.
The surgery is often performed on an outpatient basis, allowing the patient to return home the same day. Recovery is typically rapid, with many individuals returning to light activities within a few days. Surgeons usually advise against heavy lifting or strenuous activity for six to eight weeks to allow the repair site to fully heal.
Potential Complications
While many epigastric hernias remain small and manageable, a serious risk is the contents becoming permanently trapped, known as incarceration. This occurs when the tissue cannot be pushed back into the abdomen. An incarcerated hernia can lead to a painful obstruction, causing symptoms like nausea, vomiting, and an inability to pass gas or have a bowel movement.
A more severe, life-threatening complication is strangulation, which occurs when the blood supply to the trapped tissue is cut off. Strangulation can lead to tissue death, or gangrene, within hours, requiring immediate surgical intervention. Signs of strangulation include sudden, severe pain and discoloration of the skin over the hernia site.